SEXUAL MISCONDUCT INCIDENT REPORT FORM

RADFORD UNIVERSITY

This form is for reporting a sexual misconduct to the Office of Substance Abuse and Sexual Assault Education, to assist with the completion of statistical records for assaults that occur to RU students, both on- and off-campus. Filing this form will not result in an investigation, but is intended to convey needed information to assist RU in addressing the issues of sexual assault. Information contained on this form will remain confidential and will only be used in non-identifying ways. Return this form to the Coordinator of the Office of Substance Abuse and Sexual Assault Education, Box 7008, phone 831-5709.

Reporter’s name ­­­­­­­­_______________________ Dept.  __________________

Phone________________

Date of report  __________________     Date of Incident _______________

Time of incident ____________

VICTIM/SURVIVOR INFORMATION

NAME/INITIALS/OTHER IDENTIFYING INFORMATION _____________________

AGE ___________

(an anonymous report may be filed, if preferred)

VICTIM RESIDENCE              GENDER        RACE/ETHNICITY          RU AFFILIATION

_____ Off campus                  ___ Female       ____ White                      ____ Student

_____ On campus                  ___ Male            ____ Black                      ____ Faculty

                                                ___ Unknown    ____ Asian                      ____ Staff

                                                                          ____ Hispanic                 ____ None

                                                                          ____ Middle Eastern       ____ Other

                                                                          ____ Native American

ADDRESS: _____________________           ____ Other

(optional)    ______________________           ____ Unknown

DISABILITY

            ____ None       ____ Hearing

            ____ Sight       ____ Physical

            ____ Mental     ____ Unknown

SEXUAL MISCONDUCT INFORMATION

Describe the incident, check all that apply

____ Rape (sexual intercourse against the will by force, threat, or intimidation)

____ Forced sodomy (anal intercourse)

____ Forced oral copulation (oral-genital contact)

____ Forced sexual penetration by a foreign object, including a finger

____ Sexual battery (forced touching of intimate parts, fondling, kissing, but not penetration)

____ Attempts of any of the above, be specific _________________________________

____ Sexual harassment

TYPE OF COERCION/FORCE INVOLVED

____ Verbal pressure, arguments, or disregarding victim’s lack of consent

____ Stalking

____ Position of authority (teacher, supervisor, boss, etc.)

____ Threat of physical force (threatened to hit, hold down, or otherwise injured)

____ Actually used physical force (hit, held down, twisted arm, hurt, etc.)

____ Presence of weapon, be specific ________________________________

Victim/survivor was significantly incapacitated by

            ___ alcohol  ___ other drugs  ___ sleep  ___ disability ___ other

Alcohol/other drugs were used by t he victim/survivor ____  By the assailant ____

Location of incident ___ on campus               ___ off campus

Address (if known) ___________________________________________________

___ Victim’s residence                       ___ Outdoors              ___ Workplace

___ Assailant’s residence                   ___ Vehicle                 ___ Parking lot

___ Other campus facility                   ___ Other

Describe the nature of the relationship between the victim/survivor and the

assailant (s) prior to the assault

            ___ Former romantic relationship      ___ Ongoing romantic relationship

            ___ Stranger   ___ Study partner       ___Friend or non-romantic acquaintance

            ___ Relative    ___ Planned date        ___ Impromptu date (met at party or bar)

ASSAILANT INFORMATION

Number of assailants ________

Residence ___ On campus   ___ Off campus          Gender            Race/Ethnicity

                  ___ Unknown                                            ___ Male            ___ White

                                                                                    ___ Female       ___ Black

                                                                                    ___ Unknown    ___ Asian

                                                                                                              ___ Hispanic

RU Affiliation                Disability                                                            ___ Middle Eastern

___ Student                 ___ None                                                         ___ Native American

___ Faculty                 ___ Hearing                                                     ___ Other

___ Staff                      ___ Sight                                                         ___ Unknown

___ None                     ___ Physical

___ Unknown              ___ Mental      

                                    ___ Unknown

CONTACTS AND SERVICES

Victim/Survivor has reported assault to

            ___ Sexual assault educator                          ___ Dean of Students

___ Residence Life (RA or RD)                      ___ Center for Counseling and

                                                                                    Student Dev.

___ University Police                                      ___ Student Health Center

___ Local Police                                             ___ Faculty or staff member

___ Local hospital                                          

___ Rape crisis hotline