This form is intended for use in cases of rape and/or sexual assault or attempted
rape and/or sexual assault.
Do not complete this form in presence of the assault survivor.
Do not include the survivor's name or other identifying information (e.g. student
identification number, address, phone no.) on this form.
Record as much requested data as possible based on information volunteered or discussed.
Do not pry for information, just list the information obtained in the conversation.
Complete this form even if the survivor indicates that he or she has spoken with another
person on-campus and even if you will be referring the survivor to another department.
Completed form will be sent to the Coordinator of the Sexual Assault Crisis Consultation
Team.
