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:*

FemaleMaleTransgender
Affiliation to NCCC:*

StudentFacultyStaffNot Affiliated
Where does the victim/survivor live?*

Residence HallOff-Campus
Date and Time of Assault:*

MonthDayYearHourMinutesAM/PM Option
Type of Assault: check all that apply (includes pentration by penis, finger, or object)*

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

Victim's place of residenceOffender's place of residenceResidence HallOff-campus HouseRestaurant or BarOutdoorsWorkplaceParking LotCar/VehicleCampus building other than a residence hallOther
Place of Assault: (check all that apply)*

Victim's place of residenceOffender's place of residenceResidence HallRestaurant or BarOff-campus HouseOutdoorsWorkplaceParking LotCar/VehicleCampus building other than a residence hallOther
Number of Offenders*

12-34-55 or more
Sex of Offender(s):*

MaleFemaleMultiple MalesMultiple FemalesMales and Females
Affiliation to NCCC: (if known)*

StudentFacultyStaffNot affiliatedUnknown
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 HallOff-Campus
Offender's relationship to the person assaulted: Check all that apply*

Current boyfriend, girlfriend, partner, loverEx-boyfriend, girlfriend, partner, loverAcquaintanceMet same dayFriendStrangerCo-worker/colleagueFacultyStaffStudentSpouseOther
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 ServicesYes, Niagara County Sheriff OfficeYes, New York State PoliceNo legal actionDon't knowUndecided
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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