Sexual Assault Anonymous Report

This form is for reporting a sexual assault anonymously to Old Westbury University Police, to assist with the compilation of statistical records for assaults that occur on the campus. In compliance with the federal Student Right to Know and Campus Security Act. Filing this form will not result in an investigation. A person who has been assaulted may fill out this form himself or herself and send it to University Police or may ask a third party (such as a friend or a counselor) to do so.

Campus personnel other than those with significant counseling responsibility (such as licensed professionals or certified counselors) must file a report when informed by a student of a sexual assault, to maintain campus compliance with the Federal Crime Awareness Act.

Please complete the form below.

Victim's information
Affiliation to college
Racial ethnicity
Information on the Assault
Type of Coercion/Force
Reported assault
Check all that apply.
Place of assault
Was the victim using drugs and/or alcohol at the time of assault?
Check all that apply.
If yes, did he or she feel pressured to consume or use?
Offender's information
Affiliation to college
Sex of offender(s)
Residence of offenders
Racial ethnicity
Offender's relationship to victim
Age(s) of offender(s) at the time of assault
Was offender using drugs and/or alcohol at the time of assault?
Check all that apply.
If yes, was offender feel pressured to consume or use?
What resources has this person utilized thus far?
Has the assaulted person been advised of campus medical, counseling, academic, residential, and disciplinary support actions?
Person making report