1. Date of Report:
   Time: am pm
2. Date of Assault:
   Time: am pm
3. Specific Location if Available:
   

Information on the Victim/Survivor

1. Sex: Female Male
2. Age:
3. Affiliation to UB:
   Undergraduate Student Staff
   Graduate Student Not Affiliated
   Professional Student Faculty
   Other
4. Residence:
   Residence Halls Off-Campus - University Heights
   Fraternity/Sorority Off-Campus - With Family
   Off-Campus - Other
5. Racial Ethnicity:
   Asian Native American
   Black Hispanic
   White Other

Information on the Assault

1. Type of Coercion/Force:
   (Check all that apply)
   Verbal Physical Abduction
   Presence of Weapon 0ther
2. Reported Assault: (Check all that apply)
   Sexual Assault (Verbal)
   Completed Rape: (vaginal or anal)
   Sexual Assault (Physical) Attempted Rape
3. Place of Assault:
   Victim's Home Residence Hall
   Offender's Home Outdoors
   Workplace Parking Lot
   Public Campus Facility
   Car/Vehicle North Campus
   Fraternity/Sorority House South Campus
   Other Campus Property
   Other:
4. Was the person who was assaulted using drugs and/or alcohol at the time of assault?
   Alcohol: Yes No
   Drugs: Yes No
5. If yes, did he or she feel pressured to consume or use?
   Yes No

Information on the Offenders

1. Number of Offender(s):
   1 2-3 4-5 5 or more
2. Sex of Offender(s):
   Male Multiple Females
   Female Males and Females
   Multiple Males
3. Race/Ethnicity:
   Asian Native American
   Black Mixed
   Hispanic Other
   White Unknown
4. Affiliation to UB: (if known)
   Undergraduate Multiple Offenders
   Student of Different Affiliations
   Graduate Student Not Affiliated
   Professional Student Other
   Faculty Staff
5. Residence of Offenders: (if known)
   Residence Halls Off Campus
   University Heights
   Fraternity/Sorority Off Campus-Other
   Unknown
6. Age of Offender (estimated) at Time of Assault: (Check all that apply)
   If Single Offender:
   13-19 20-25 26-30 31-40 Other
   If Multiple Offenders:
   13-19 20-25 26-30 31-40 Other
7. Offender's Relationship to the person assaulted:
   Partner/Lover Acquaintance
   Ex-Partner/Ex-Lover Met same day, socially
   Spouse Met same day, non-socially
   Stranger Student
   Colleague/Co-worker Faculty/Teaching Assistant
   Staff
8. Was offender using drugs and/or alcohol at time of assault?
   Alcohol: Yes No
   Drugs: Yes Don't know
9. If yes, was offender pressured to consume or use?
   Yes No Don't know

Follow-Up

1. Does the assaulted person plan to seek legal or UB disciplinary action against the offenders?
   Yes, inside UB through:
        Judicial Affairs     
        Residence Halls
   Yes, outside UB
   No
   Don't know
2. What resources has this person utilized thus far?
   Student Affairs
   Medical Campus Health Service
   Police On-Campus Police
   Religious Organizations Campus Ministries
   Department Office/Academic Unit
   Residence Hall Staff
   Undergraduate Advising Office
   Judicial Affairs Personnel Office
   Other
3. Has the assaulted person been advised of campus medical, counseling, academic, residential, and disciplinary support actions?
   Yes No Don't know

Person Making Report (optional)

Name:

Address:

Telephone:

Notes/Comments/Description of Offender: