Central Connecticut State University

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






Attacker 2:
Name
Location







Attacker 3:
Name
Location






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