Anonymous Sexual Violence Incident Report

Instructions: This form is intended to convey information needed to track the university’s response to the incident being reported, as well as to assess the danger that the incident may represent to the campus community at large. All efforts must be made to maintain the survivor’s anonymity; no information should be included which might identify the survivor, unless he or she asks you to do so. All information contained on this form will be kept confidential except in the case of an ongoing threat to the community that St. Lawrence University is obligated to address.   Completing this form does NOT constitute a police report nor a student conduct report. The survivor will not be contacted by the university unless he or she indicates a desire to be contacted. If you have any questions, please contact the Advocates Program Director at 229-5122 or if it is after hours, call the Sexual Violence Hotline at 244-5466.
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Reporting Person’s Information: (optional)

Name:

Year/Department:

Date:

Phone:

Relationship to Survivor:


Survivor’s Information:

Gender: Age: Year:
Date & Time of Incident:
(if exact date/time unknown, please estimate)
Location of Incident:
Type of Assult: rape attempted rape relationship violence
stalking sexual assult sexual misconduct
Were any of the following involved: knife gun other weapon
force drugs alcohol
threat of death abduction person asleep
verbal coercion physical coercion other

Additional Details:



Offender’s Information:

# of offender: Gender(s): Age(s):
Affiliation with SLU: Residence:
Relationship to Survivor: Partner or lover Ex-partner/spouse/lover spouse
Colleague Supervisor Faculty or TA
Acquaintance Met same day Stranger
Other:
Name: (optional) Permission to give to Security: yes no

Follow-Up Information:
What, if any, has the survivor used so far?
Sexual Violence Hotline Counselling Center Associate Dean's Office
Advocates Program Safety & Security University Chaplain
Health Services Dean's Office Faculty/Staff mentor
Residence Life CAVA Renewal House
Catholic Charities Canton Police Dept. Reachout Hotline
Canton Potsdam Hospital Other:
Is there any other information the survivor wishes to share?