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
Date Picker Icon
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
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)
Other
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
Other
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
Other
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
Other
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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