UNIVERSITY OF VIRGINIA

Anonymous Sexual Assault Report Form

For Use By University of Virginia Students Only

What is a Third-Party or Anonymous Report?
An anonymous report is an unofficial means to inform the University administration that a sexual assault has occurred. It was developed to encourage reporting by students without risk of exposure or being forced to file charges. Because this is unofficial, the police cannot make an arrest based on this report, but it will provide useful information to the police, administration, and the Sexual Assault Education Coordinator regarding the types of assaults that are occurring here. You may file a Third-Party/Anonymous Report whether or not you later file a criminal complaint, or use any of the internal adjudication options at UVA. The report itself is kept on file at the University Police Department. If you send the report through this web page, however, the information will be sent without identifying headers to the Sexual Assault Education Office, where a form will be filled out based on the responses you provide. That form, in turn, will be sent to the police department.

IMPORTANT NOTE REGARDING CONFIDENTIALITY: Although in most cases the information you send will remain anonymous, nothing is ever completely confidential on the internet. Files may be illegally hacked into. In addition, if a criminal or civil case were to be filed, it is theoretically possible for the identity of the sender to be discovered if a subpoena were filed for this record, although, this would be an unsual situation. For greater security, if you send this form from a computer lab, AFTER you send your form, hit control-al-delete and the record of your form will be deleted from the server. If you have any concerns about confidentiality, you may wish to file your Third Party Report by calling SARA at 977-7273 or the Sexual Assault Education Office at 982-2774 without identifying yourself.

How do I fill this out?
The process is simple. If you prefer not to use the web, you can call the Sexual Assault Education Office (SAEO) at 982-2774, and one of the staff members will help you fill one out either in person or over the telephone. Alternatively, if you call SARA (977-7273), Office of the Dean of Students (Dean Sisson at 924-7427) or the UVA Police (924-7166), they also can help you do this by phone. If you want to send it electronically, continue on to the form below. You don't have to answer any questions that seem inappropriate to you or that you are uncomfortable answering.

For purposes of this form, "sexual assault" has the same definition as that outlined by the University of Virginia Sexual Assault Board:

Sexual Assault is: sexual intercourse without consent, forcible sodomy or sexual penetration with an inanimate object, the intentional touching of an unwilling person's intimate parts (defined as genitalia, groin, breast, or buttocks, or clothing covering them), or forcing an unwilling person to touch another's intimate parts. To constitute an assault, the above acts must be committed either by force, threat, surprise or intimidation, or by taking advantage of someone's helplessness or inability to consent of which the alleged perpetrator was aware or should have been aware.

If you aren’t sure your experience would be technically defined as sexual assault, or, if you are certain you were assaulted, but aren’t sure how well the assault fits into the definition, fill the form out anyway. We can make the determination whether or not this is an assault. Even if it is not, the information you provide can influence the direction of educational efforts at UVA. Again, if you’d like to call someone anonymously to discuss this, contact SARA or the SAEO.

The process of filling out this form may raise painful feelings. If you are not already receiving counseling, or never received any counseling about your assault, do not hesitate to call the SARA 24-hour hotline at 977-7273.

Use Submit Responses to submit your answers.

Part I   (Please select appropriate answer):

  1. The individual filling out this form is:
  2. Date of assault (please enter):     
  3. Time of day  (if known):     
  4. The victim knew the alleged perpetrator(s).     

Part II: Victim Information   (Please select appropriate answer):

5.     Sex:    
6.     Age:    
7.     UVA Student:    
8.     If a UVA student, please indicate what year:
9.     Living:    

Part III   (Please select appropriate answer):

Assailant No. 1
10.   Name of assailant (optional):    
11.   Sex:    
12.   Age  (enter):    
13.   UVA student:    
14.   If known, what year:    
15.   Living:    
16.   Approximate height:    
17.   Approximate weight:    
18.   Color eyes:    
19.   Color hair:    
20.   Length of hair:    
21.   Facial hair:    
22.   Race or ethnicity  (best guess):     
23.   Wears glasses?    
24.   Distinctive scars  (describe):

25.   Distinctive marks  (describe):

26.   Tattoos  (describe and state where placed):

27.   Odors  (describe):

28.  Describe clothing:

29.   Describe speech, accents:

30.   Unusual phrases or actions (exact language) used to describe male/female genitals, intercourse, etc.

31.   Evidence of drug or alcohol use?     
32.   Was assailant (check all that apply):
Apologetic
Ignoring your efforts to persuade him to stop
Abusive
Threatening
Blocking your exit or using his body to restrain you
Brandishing a weapon

If there was one perpetrator, click here to skip to number 80.

Assailant No. 2
33.   Name of assailant (optional):    
34.   Sex:    
35.   Age  (enter):    
36.   UVA student:    
37.   If known, what year:    
38.   Living:    
39.   Approximate height:    
40.   Approximate weight:    
41.   Color eyes:    
42.   Color hair:    
43.   Length of hair:    
44.   Facial hair:    
45.   Race or ethnicity  (best guess):     
46.   Wears glasses?    
47.   Distinctive scars  (describe):

48.   Distinctive marks  (describe):

49.   Tattoos  (describe and state where placed):

50.   Odors  (describe):

51.  Describe clothing:

52.   Describe speech, accents:

53.   Unusual phrases or actions (exact language) used to describe male/female genitals, intercourse, etc.
>

54.   Evidence of drug or alcohol use?     

55.   Was assailant (check all that apply):
Apologetic
Ignoring your efforts to persuade him to stop
Abusive
Threatening
Blocking your exit or using his body to restrain you
Brandishing a weapon

If there were two perpetrators, click here to skip to number 80.

Assailant No. 3
56.   Name of assailant (optional):    
57.   Sex:    
58.   Age  (enter):    
59.   UVA student:    
60.   If known, what year:    
61.   Living:    
62.   Approximate height:    
63.   Approximate weight:    
64.   Color eyes:    
65.   Color hair:    
66.   Length of hair:    
67.   Facial hair:    
68.   Race or ethnicity  (best guess):     
69.   Wears glasses?    

70.   Distinctive scars  (describe):

71.   Distinctive marks  (describe):

72.   Tattoos  (describe and state where placed):

73.   Odors  (describe):

74.  Describe clothing:

75.   Describe speech, accents:

76.   Unusual phrases or actions (exact language) used to describe male/female genitals, intercourse, etc.

77.   Evidence of drug or alcohol use?     
78.   Was assailant (check all that apply):
Apologetic
Ignoring your efforts to persuade him to stop
Abusive
Threatening
Blocking your exit or using his body to restrain you
Brandishing a weapon

79.   Were more than three assailants involved?     
        If yes, how many?     

Part IV:   Assault Information

80.   Location of assault:    

81.   Brief description of assault:

82.   Was either party under the influence of alcohol or other drugs:     
83.  Did the victim receive emergency treatment?     
       If yes, please explain:

84.   Has the victim also reported to the legal authorities:     
        If yes, which agency?     
        If no, explain why?

85.   Has the victim sought assistance from any of the following (check all that are appropriate):
UVA Sexual Assault Education Office
UVA Student Health:
      Gynecology
      General Medicine
      Counseling and Psychological Services
      Health Education
UVA Office of the Dean of Students
SAFE (Sexual Assault Facts & Education)
University Judiciary Committee
Sexual Assault Resource Agency

Optional Information

86.   I wish to be contacted in the event that other victims report similar assaults or someone files a criminal complaint against this perpetrator.     

Tell us how to get in touch with you:

Name
E-mail
Phone
Mailing Address

Please contact me as soon as possible regarding this matter.

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Copyright © 1998, 2001 Sexual Assault Education Office.
Revised: August 17, 2001.