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Division of Student Affairs

Anonymous Report Form Sexual or Relationship Violence Incident

Vice President for Student Affairs
210 Werner University Center
503-838-8221

Student Health and Counseling Center
503-838-8313

Information on the Survivor

Name: (optional)	Gender: *required	Date of Birth: Providing date of birth is a confidential means to differentiate incidents and reduce duplicate statistics.
Survivor's affiliation with WOU (check all that apply): Undergraduate Student Graduate Student English Language Study Center Faculty Staff Not Affiliated Unknown Other:	Offender's affiliation with WOU (check all that apply): Undergraduate Student Graduate Student English Language Study Center Faculty Staff Not Affiliated Unknown Other:	Offender's relationship to the assaulted person (check all that apply): Partner or lover Ex-partner, ex-spouse or ex-lover Spouse Colleague or coworker Work supervisor Acquaintance Met same day, socially Met same day, non-socially Stranger Other:
	Offender(s) residence: Residence Hall Off-campus WOU family housing Other:

Information on the Assault

If a survivor wishes for the assault to be recorded in university statistics, this section must be completed in full. All mandatory reporters are required to complete this section as well.
Date of assault:	Time of assault:
Was coercion or force involved? (check all that apply): Verbal Physical Presence of Weapon Threat of Death Abduction Incapacitation due to drugs Incapacitation due to alcohol Other:	Place of assault (check all that apply): Residence Hall WOU family housing Other:	Does the survivor believe he /she was given a drug without his /her consent or knowledge? Yes No Unknown
Note: An incident does not have to involve coercion or force to be considered a student conduct violation. Reporting drug or alcohol use here will not result in any sanctions for the survivor. For more information, contact the Office of Judicial Affairs. Please give a brief description of the incident: If a survivor wishes for the assault to be recorded in university statistics, this section must be completed in full. All mandatory reporters are required to complete this section as well. Additional room is provided on the back of this form. Additional pages may also be attached.

Follow-Up

To your knowledge, has this incident been reported to the police, Campus Public Safety, or Student Conduct?

Yes

Unknown

If no, what were the reasons for not reporting?

If yes, please list agencies that received report:

What was the response or action?

If there was a response, were you satisfied?

Yes

What resources has the survivor used so far?

Office of the Vice President for Student Affairs office

Student Health & Counseling Center

Office of International Programs & Scholars

WOU Campus Public Safety

Planned Parenthood

Director of Multicultural Student Services & Programs

Monmouth or Independence Police

Salem Hospital

Mid-Valley Women's Crisis Services

Other:

Information about the Person Completing this Form

I am the

Survivor or Victim

Witness or observer

Agency or staff person

Roommate or housemate

Family member

Partner

Friend

Other:

Would you like to be contacted by

Vice President for Student Affairs

Campus Public Safety

Student Health and Counseling Center

Office of Judicial Affairs

Office of Student Conduct

Police Department

Other:

Report Date:

Contact

Office of the Vice President for Student Affairs 503-838-8221 | or e-mail: studentaffairs@wou.edu

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