Instructions: This form is intended to collect survey information needed to assist in prevention training programs, victim assistance, and response training. All efforts must be made to maintain the victim’s anonymity on this survey. No information should be included which might identify the victim. Complete as much of the survey as possible. The shaded areas are essential. Please return this form to the Sexual Response Coordinator within 24 hours. Discuss the limits to confidentiality prior to discussing the details of a sexual assault. Explain to the victim that basic information about the incident will be shared with the Sexual Assault Response Coordinator. The Coordinator will share the information with those individuals who are on a “need to know basis” only, including the campus police. Individuals should discuss the type of information to be released and should obtain a signature regarding the release information and /or have the person sign the bottom of the protocol checklist. Press/media inquiries should be referred to the Sexual Assault Response Coordinator or Vice President of Student Affairs. When the incident occurred on campus, the incident must be reported to the campus police who will investigate.

Reference # ______(birth month and day) Date of Report ______ Date of Incident _____

Reporter’s Name _________________ Position/Dept. _________________

Phone # _____________ Victim’s age _____ Victim’s Gender _____

Victim’s Academic Year _____ Time or Incident _____ Occurred on campus? Yes No

Describe Location (building name, street, etc.)

_______________________________________

Describe Assault (Check one)

__ sexual contact (fondling, kissing, petting but not penetration) without consent

__ attempted intercourse without consent (penetration did not occur)

__ intercourse (oral, anal, or vaginal penetration by penis or other object) without consent

__ other (describe) ________________________________________________________

Was the absence of consent due to the victim being incapacitated by:
Alcohol? Yes No
Drugs? Yes No

Describe the kind of pressure or force used by the assailant:

__ none

__ verbal pressure or arguments

__ position of authority (boss, teacher, supervisor)

__ threat of physical force (threatened to hit, hold, or otherwise injure)

__ actual use of physical force. (Hit, held victim down, twisted arm etc...)

__ gave victim alcohol or drugs so that victim was significantly incapacitated

Was a weapon involved in the assault? Yes No
(If yes, type of weapon: __________________)

Number of Assailants _____
Describe: gender ____ race ____ age ____ height _____ weight ____

Role of Assailant on Campus: Student ___ Faculty ___ Staff ___ Other _____ None ___

Nature of relationship with victim prior to incident (check one)

stranger ___ spontaneous date ___ planned first date ___ relative ___ spouse/partner ___

friend or nonromantic acquaintance ___ romantic acquaintance or ongoing date ___

Name of Alleged Assailant(s): ______________________________
(see reporting responsibilities in “Role...”)

Other contact points the victim reported this assault to:

Sexual Response Coordinator ___ Student Health Service ___Campus Ministries ___

Residential Education ___ Dept of Public Safety ___ Morgantown Police ___

Carruth Counseling Center ___ Student Life ___ Social Justice office ___

RDVIC Crisis Shelter ____ Other_____________________________________________

Name of Victim: (optional)___________________________________________________

Complete the checklist ? Yes No

Send this form to: Deb Beazley Sexual Assault Response Coordinator, PO Box 9247, Morgantown WV, 26506, 293-1377, dbeazley@wvu.edu.