Confidential Sexual Assault Report Form

Date of Report ____________________________________ Time ______________

Date of Assault ___________________________________ Time ______________

Place of Assault ______________________________________________________

The Security and Campus Safety Department will be notified only of
the number of Confidential Reports filed.  No additional information
will be reported.

All information will remain confidential.
If you wish to describe the incident, please do so in the space below.
Additional paper may be used.  The perpetrator's name MAY be
included in this report, but is not required.  IF you choose to 
identify the perpetrator, please indicate whether you wish to be notified 
if the perpetrator's name reappears in our confidential files.  Being 
notified does not in any way oblige you to go forward with further action.

If you wish to be contacted, please sign here. __________________________