UCO: Sexual Assault Form

Division of Student Affairs
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UCO Student Conduct: Sexual Assault Anonymous Reporting Form

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I. Information on the Victim/Survivor
*Sex:
*Age:
*Affiliation to UCO:
*Where does the victim reside?:
II. Information on the Assault
*Type of Coercion/Force: (Check all that apply):		Verbal Physical Abduction Presence of Weapon Threat of Death Date Rape Drug Other
*Reported Assault: (Check all that apply):		Sexual Assault (Verbal) Sexual Assault (Physical) Attempted Rape Completed Rape (Vaginal) Completed Rape (Oral) Completed Rape (Anal)
*Place of Assault:
Was the person who was assaulted under the influence of alcohol and/or drugs at the time of assault?
*Alcohol:
*Drugs:
If YES, did he or she feel pressured to consume or use?
Pressured?:
If yes, then please identify the source of the pressure. (Check all that apply)
Source of pressure:		The Offender(s) Friend(s) Organization 3rd Party Vendor Other Entity
III. Information on the Offender(s)
*Number of Offender(s)::
Sex of Offender(s): (Check all that apply)
*Offender Gender:		Male Female Multiple Males Multiple Females Male and Female
*Affiliation to UCO::
Residence of Offender(s):
Estimated Age of Offender at Time of Assault
*Age:
If Multiple Offender(s): (Check all that apply)
*Ages:		13-17 18-20 21-25 26-30 31-40 40+ Unknown
Relationship of Offender(s) to the person assaulted: (Check all that apply)
*Relationship:		Partner/Lover Acquaintance Ex-Partner/Ex-Lover Spouse Met same day, socially Met same day, non-socially Stranger Student Colleague/Co-Worker Faculty/Teaching Assistan Staff Other Unknown
Was Offender(s) under the influence of alcohol and/or drugs at time of assault?
*Alcohol:

*Drugs:
IV. Plans for Follow-Up Actions Does the assaulted person plan to seek legal or disciplinary action against the offender(s)?
*Action:
Has the assaulted person been advised of University Health Services and / or Local Hospitals, the Student Counseling Center, the Violence Prevention Project (VPP) Office, the Office of Student Conduct, academic options for the semester, and/or temporary residential options through Housing and Dining Services?
*Advised?:
Has the assaulted person utilized any of the following resources: University Health Services and / or Local Hospitals, the Student Counseling Center, the Violence Prevention Project (VPP) Office, the Office of Student Conduct, Academic Advisement, and/or temporary residential options through Housing and Dining Services?
*Used resources?:

University of Central Oklahoma

Student Conduct

A Department of Student Affairs