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Required Information
Sexual Assault Anonymous Report
Date Assault Occurred
*
Enter date as (MM/DD/YYYY) or indicate a time period
Time Assault Occurred
Please indicate a time, if possible, or a time period and include either AM or PM.
Specific Location
*
On Campus
Off Campus
Unknown
Location Detail
To the best of your ability, please tell us more about the location where the assault occurred.
About the Victim or Survivor
Gender
*
Man
Woman
Non-binary or other
Age
Affiliation to UB
Undergraduate Student
Staff
Graduate Student
Not Affiliated
Professional Student
Faculty
Other
Unknown
Prefer Not to Answer
Residence
*
Residence Halls
Off-Campus — University Heights
Fraternity or Sorority
Off-Campus — With Family
Off-Campus — Other
Unknown
Prefer Not to Answer
Racial Ethnicity
Asian
Native American
Black
Hispanic
White
Other
Unknown
Prefer Not to Answer
About the Assault
Type of Coercion or Force: (Choose all that apply)
Verbal
Physical
Abduction
Presence of Weapon
Other
Reported Assault: (Choose all that apply)
Sexual Assault (Verbal)
Completed Rape — Vaginal
Completed Rape — Anal
Sexual Assault (Physical)
Attempted Rape
Place of Assault
*
Victim's Home
Residence Hall
Offender's Home
Outdoors
Workplace
Parking Lot
Campus Facility Open to the Public
Car or Other Vehicle
North Campus
South Campus
Downtown Campus
Fraternity or Sorority House
Other Campus Property
Other (please specify)
Unknown
Prefer Not to Answer
If "Other" Please Specify
To the best of your knowledge, were drugs or alcohol used at the time of the assault?
Alcohol: Yes
Alcohol: No
Drugs: Yes
Drugs: No
Unknown
If yes, to the best of your knowledge, did the victim or survivor feel pressured to consume or use the drugs or alcohol?
Yes
No
Unknown
About the Offender(s)
Number of Offenders
1
More than 1
Possibly more than 1
Unsure
Affiliation to UB
Undergraduate
Multiple Offenders
Student of Different Affiliations
Graduate Student
Professional Student
Faculty
Staff
Other
Not Affiliated
Unknown
Prefer Not to Answer
Sex of Offender(s)
Male
Femaie
Multiple Males
Multiple Females
Males and Females
Other
If "Other" Please Specify
Residence of Offender(s)
Residence Halls
Off Campus
University Heights
Fraternity or Sorority
Off-campus - Other
Unknown
Prefer Not to Answer
Race or Ethnicity
Asian
Native American
Black
Mixed
Hispanic
White
Other
Unknown
Prefer Not to Answer
Offender's Relationship to the Person Assaulted
*
Partner or Lover
Acquaintance
Ex-partner or Ex-lover
Met same day, socially
Spouse
Met same day, non-socially
Stranger
Student
Colleague or Co-worker
Faculty or Teaching Assistant
Staff
Other
Prefer Not to Answer
If Single Offender — Age of Offender (estimated) at Time of Assault
High School-aged
College-aged
Older Than College-aged
Unknown
Prefer Not to Answer
If Multiple Offenders — Age of Offenders (estimated) at Time of Assault (Choose all that apply)
High School-aged
College-Aged
Older than College-aged
Unknown
Prefer Not to Answer
To the best of your knowledge, was offender(s) using drugs or alcohol at time of assault? (choose all that apply)
Alcohol: Yes
Alcohol: No
Drugs: Yes
Drugs: No
Unknown
If yes, to the best of your knowledge, was offender(s) pressured to consume or use drugs or alcohol?
Yes
No
Don't know
Follow-Up
Does the assaulted person plan to seek legal or UB disciplinary action against the offender(s)?
Yes, inside UB through Judicial Affairs
Yes, inside UB through Residence Halls
Yes, outside UB
No
Don't know
What resources has this person utilized thus far?
Student Affairs
Off-campus Medical
Campus Health Service
Hospital
Police
On-campus Police
Religious Organizations
Campus Ministries
Department Office or Academic Unit
Residence Hall Staff
Undergraduate Advising Office
Judicial Affairs
Personnel Office
Other
Unknown
Prefer Not to Answer
If "Other" Please Specify
Has the assaulted person been advised of campus medical, counseling, academic, residential, and disciplinary support actions?
*
Yes
No
Don't know
About the Person Making the Report (optional)
Name
First Name
Last Name
Address Line 1
Address Line 2
City
State, Province or Region
Zip or Postal Code
Country
Phone
(area code) XXX-XXXX
Notes, Comments or Description of Offender
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