Sexual Assault Anonymous Report Form

The college takes sexual harassment, including issues of sexual and interpersonal violence, seriously.  If you as a student complainant or reporter wish to remain anonymous, fill out this Anonymous Report Form. The college will use this information for statistical purposes, to better understand the scope of sexual violence on campus, and to develop and implement preventive efforts. If you fill this form out with a college employee, the report will no longer be anonymous.

The college is required to investigate allegations of sexual misconduct to the best of its ability.  As a result, the college will follow up on any specific, identifying information provided in this anonymous report.

Complainant Information

* indicates a required field.

       
  How does the complainant identify Male
Female
Transmale
Transfemale
Genderqueer
Other
 
  Complainant's affiliation to Westminster College (check all that apply) Student
Staff
Faculty
Alumni
Not Affiliated
Unknown
Other
 
  Complainant's Age  

Accused Information

  How does the accused identify (check all that apply): Male
Female
Transmale
Transfemale
Genderqueer
Other
 
  Accused's Age  
  Accused's affiliation to Westminster College Student
Staff
Faculty
Alumni
Unknown
Other
 
  Accused's Relationship to the Complainant 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
Friend
Other (Please Specify)
 
  If other, please describe  
  Was the accused using drugs and/or alcohol at the time of the assault? Yes (drugs)
Yes (alcohol)
No
Do not know
 
  If more than one accused, please indicate number of accused:  
  Accused's Name (if known, optional)*  

*Please note, if this information is given, the college has a duty to investigate the incident further.

Incident Information

  Approximate Time of Incident  
  Approximate Date of Incident  
  Location(s) of Incident On Campus
Off Campus
Carleson
Hogle
Stock
Behnken
Olwell
On the Draw
Century
Villa Darvi
Academic Building
Parking Lot
Not sure of location
Other
 
  If other, please specify  
  Type of Force/Coercion Involved (check all that apply) Verbal
Threat of Death
Physical
Abduction
Presence of a Weapon
Incapacitation due to drugs*
Incapacitation due to alcohol*
Manipulation
Position of authority
Sexual Harassment
Stalking
Other
 
  If other, please describe  

*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 complainant. 

  Please give a brief description of the incident. If a complainant wishes for the assault to be recorded in the college statistics, this question must be completed in full. All mandatory reporters are required to complete this section as well.
 
  To your knowledge, has this incident been reported to the police, Campus Public Safety, or Dean of Students Office?  
  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?  
  What resources has the complainant used so far? Dean of Students Office
Residence Life
Counseling Center
Student Health Services
Campus Patrol
Rape Recovery Center
Planned Parenthood
Hospital
Police
Other
 
  If other, please describe  

Information about the Person Completing this Form

  I am the/a Complainant or Victim
Witness or observer
Roommate or housemate
Family member
Partner
Friend
Advocate
Faculty or Staff
 
  If faculty/staff, please list your name  

Follow-Up Information

Please note, if you list your name and/or contact information, this report will no longer be anonymous. This section is completely optional.

If you would like to be contacted by Westminster College and this incident to be investigated further, please list your name and contact information

  Name  
  Phone Number  
  Email