Anonymous Sexual Assault Report

Anonymous Sexual Assault Report

This form is for reporting a sexual assault anonymously to NCCC. The information helps NCCC better respond to victims of sexual assault. Filing this form will not result in an investigation. A person who has been assaulted may fill out this form himself or herself, or may ask a third party (such as a friend or a counselor) to do so.
Gender: *

Female Male Transgender
Affiliation to NCCC: *

Student Faculty Staff Not Affiliated
Where does the victim/survivor live? *

Residence Hall Off-Campus
Date and Time of Assault: *

Month Day Year
at
Hour Minutes AM/PM Option Date Picker Icon
Type of Assault: check all that apply (includes pentration by penis, finger, or object) *

Vaginal Rape Anal Rape Forced Oral Sex (Either giving or receiving)
Where was the victim when he or she first encountered the offender? (check all that apply) *

Victim's place of residence Offender's place of residence Residence Hall Off-campus House Restaurant or Bar Outdoors Workplace Parking Lot Car/Vehicle Campus building other than a residence hall
Place of Assault: (check all that apply) *

Victim's place of residence Offender's place of residence Residence Hall Restaurant or Bar Off-campus House Outdoors Workplace Parking Lot Car/Vehicle Campus building other than a residence hall
Number of Offenders *

1 2-3 4-5 5 or more
Sex of Offender(s): *

Male Female Multiple Males Multiple Females Males and Females
Affiliation to NCCC: (if known) *

Student Faculty Staff Not affiliated Unknown
If there were multiple offenders, did they have a connection to each other (housemates, roommates, same student organization or sport)
Residence of Offender(s): Check all that apply *

Residence Hall Off-Campus
Offender's relationship to the person assaulted: Check all that apply *

Current boyfriend, girlfriend, partner, lover Ex-boyfriend, girlfriend, partner, lover Acquaintance Met same day Friend Stranger Co-worker/colleague Faculty Staff Student Spouse
Was alcohol or another predatory drug (also know as date rape drug) involved with the assault? If yes, please explain:
Does the victim plan on seeking legal or disciplinary action against the offender(s): *

Yes, NCCC Campus Security Department or Student Services Yes, Niagara County Sheriff Office Yes, New York State Police No legal action Don't know Undecided
Thank You

Thank you for completing this form. If you need assistance please contact the NCCC Campus Security Department, Wellness Center, or the YWCA Rape Crisis/Domestic Violence Hotline.
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