Third Party Relationship and Sexual Misconduct
Reporting Form
The purpose of this form is to assist the
Relationship and Sexual Violence Task Force with Statistical
information. All information given is strictly confidential.
Contact Information:
The contact information and everything else
on this form is completely optional. If at any point you no longer
wish to answer the question, skip it.
A Victim/Survivor Information
1. Sex of Victim/Survivor:
Male
Female
2. Affiliation to Central Connecticut State University
Undergraduate
Graduate
Staff
Faculty
Not Affiliated
Other
3. Victim/Survivor Lives:
On Campus
Off Campus
4. Does the Victim/Survivor believe s/he might have been given a "date rape"
drug?
Yes
No
Maybe
Could you describe the symptoms that lead you to believe that you were
given a date rape drug:
B Assault Information
Check all that applies based on the information shared
1. Sexual Assault:
Unwanted
penetration
Unwanted contact
(fondling)
Attempted Rape
Ignoring ones efforts to
persuade him/her to stop
Blocking ones exit or
using his/her body to restrain victim/survivor
Other
Sexual Harassment:
Unwanted contact
(fondling)
Sexual comments
Obscene phone calls
Unwanted e-mails
Ignoring ones efforts to
persuade him/her to stop
Blocking your exit or
using his/her body to restrain you
Other
Dating/Domestic Violence:
Physical abuse
(slapping, hitting)
Verbal abuse
Other
Abusive
Driving recklessly
Brandishing a weapon
Threatening
Controlling
Throwing things
Grabbing/Shaking
Apologetic Stalking:
2.
Other
3. Place where assault occurred:
On Campus
Off Campus
Other
4. Was drugs, alcohol or any other narcotics involved?
Alleged offender(s)
Victim/Survivor
Unknown
C Alleged Offender(s) Information:
1. Sex of alleged offender:
Male
Female
2. Number of alleged Offender(s):
3. Affiliation to the University:
Undergraduate
Graduate
Faculty
Not affiliated
Employee
Other
4. Alleged Offender(s) lives:
On Campus
Off Campus
5. Alleged Offender(s) relationship to victim:
Acquaintance
Stranger
C (part 2) Alleged Offender(s) Contact Information:
WARNING: If you fill out the
section below, then the Women's Center has no choice but to notify the
proper authorities and seek justice.
Attacker(s) information:
Please list in the space provided all the information you are willing to
divulge
Attacker 1:
Name
Location
Please discuss the attacker's role in the assault or any other information
relevant to the incident.
Attacker 2:
Name
Location
Please discuss the attacker's role in the assault or any other information
relevant to the incident.
Attacker 3:
Name
Location
Please discuss the attacker's role in the assault or any other information
relevant to the incident.
Attacker 4:
Name
Location
Filling out the information in RED will require
action on our part.
All other information is not subject to this rule.
Everything is optional, everything will be handled with the strictest
confidentiality.
D Follow-Up Information:
1. The Victim/Survivor has utilized the following
University resources:
Health Services
Counseling Services
University Police
Residence Life
Women's Center
Student Affairs Office
Personnel Office
Religious Ministry
Ombudsperson
Judicial Coordinator
Affirmative Action Office
Sexual Assault Crisis
Center
New Britain Police
New Britain Hospital
Domestic Violence Center
Other
2. Victim/Survivor plans to seek the following legal action:
Criminal/Civil Court
CCSU Judicial System
Affirmative Action Office
Undecided
Unknown
Other
E Statement
Please list below the events that took place during the
time in question to the best of your knowledge. Annominity is your right and
everything here is completely confidential.
Contact Information:
The contact information and everything else
on this form is completely optional. If at any point you no longer
wish to answer the question, skip it.
First name
Last Name
Form of contact if necessary:
(i.e. e-mail, cell-phone, address, etc.)
Date of Report
(mm/dd/yyyy):
Semester of Assault:
Fall
Spring
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