Anonymous Reporting Form
Sexual Assault on campus

The purpose of this form is to make the campus community aware of the prevalence of sexual assaults on college campuses, but ensuring complete anonymity of the victims. Colleges and universities are not safe from sexual violence. Reports indicate 1 in 5 college women will experience sexual assault during their college career. The College of St. Scholastica is a mostly a safe campus, but recognizes the dynamics of sexual assault and wants to ensure students are aware of accurate statistics that represents our campus.

The information will be anonymous unless the victim indicates they want it to be confidential. The difference between confidential and anonymous:

Anonymous: No name or identifying information is reported. This information is unofficially documented on campus safety reports

Confidential: No name or identifying information is reported UNLESS the victim chooses to pursue an official campus report or off-campus report. The information given will be included in the official campus safety report, but names and identifying information is withheld.

Reporting Information:

Today’s Date:

Are you the survivor? yes no

If no, what is your affiliation to the victim?

Survivor Information:

Gender: Male Female

Affiliation to CSS (please check):
Undergraduate student
Graduate student
Guest **if checked, enter age
Residnece Hall
Note: An incident does not have to involve coercion or force to be considered a violation of the student code of conduct. Those under the influence of alcohol may not be able to consent. For example:
Sarah is intoxicated at a party and is flirting and dancing with a number of men. She follows one guy into a bedroom and begins to kiss him. She turns away and passes out on the bed. When she wakes up, the guy is on top of her, fondling her and taking off her bra.
Victims who report alcohol or drug use will not be punished for violating the student code of conduct.

At the time of the Assault, was alcohol or drugs used? Yes No
If yes, what was used and how much?

Offender Information:

Number of offenders:
Gender of offender: male female Age of offender:
Affiliation to CSS (please check):
Undergraduate student
Graduate student
Residence of Offender:
Residnece Hall
Relationship to the victim:
Ex-partner or lover/Ex-boyfriend or girlfriend/Ex-Spouse
Work Supervisor
Acquaintance (met occasionally or have a class together)
Met the same day as the assault

At the time of the assault:
Was the offender under the influence of alcohol or drugs at the time of the assault? yes no

Information about the Assault:

Date of the Assault:

Approximate time of assault    a.m. p.m.
Location of the assault:
Residence Hall
On-campus apartment
Off campus apartment or house
Other (please specify):
Please check all that apply to the assault:
Verbal Pressure
Intimidation or coercion
Threats of harm to self or others
Physical force (pushing, held down, etc.)
Abuse of authority
Use of alcohol or drugs
Presence of a weapon
Does the victim believe that they were given a drug without their consent?
Yes No

How would you categorize the assault?(check all that apply)
Attempted rape
Completed rape
Assault (unwanted touching, fondling)

Please give a brief description of the incident:
**If the victim wishes for the assault to be considered an official report, this section must be completed.


To your knowledge, has this incident been reported to the police or to the College?
Yes No

There are resources on campus and the community to help victims, family, friends and anyone affected by sexual assault.
The services are free and confidential.

Would you like someone from the Sexual Assault Support Team to contact you? yes no

If yes, please select a method of communication:
(10-digit phone number)
Would you like to hear from:
a female
a male
Is it safe/okay to leave a message: