You must have JavaScript enabled to use this form. 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. Date of report Date of assault Time of assault Location of assault Victim's information Sex Male Female Transgender Affiliation to college None Undergraduate student Staff Graduate student Professional student Faculty Other… Enter other… Residence Campus residence halls Off-campus - with family Off-campus - other Racial ethnicity Caucasian Latino/Hispanic Middle Eastern African Caribbean South Asian East Asian Mixed Other… Enter other… Information on the Assault Type of Coercion/Force Verbal Physical Abduction Presence of weapon Other… Enter other… Reported assault Sexual assault (verbal) Completed rape (vaginal) Completed rape (anal) Sexual assault (physical) Attempted rape Check all that apply. Place of assault Victim's home Residence hall Offender's home Outdoors Workplace Parking lot Public campus facility Car/vehicle Other campus property Other… Enter other… Was the victim using drugs and/or alcohol at the time of assault? Alcohol Drugs Check all that apply. If yes, did he or she feel pressured to consume or use? Yes No Offender's information Number of offender(s) Affiliation to college Undergraduate student Multiple offenders Students of different affiliations Graduate student Professional student Faculty Staff Not affiliated Other… Enter other… Sex of offender(s) Male Female Multiple males Multiple females Male(s) and female(s) Residence of offenders Campus residence halls Off-campus - with family Off-campus - other Unknowin Racial ethnicity Caucasian Latino/Hispanic Middle Eastern African Caribbean South Asian East Asian Mixed Other… Enter other… Offender's relationship to victim Offender's relationship to victim - None -Partner/loverEx-partner/loverSpouseAcquaintanceMet same day, sociallyMet same day, non-sociallyStrangerStudentColleague-co-workerFaculty/teaching assistantStaffOther… Enter other… Age(s) of offender(s) at the time of assault 13-19 20-25 26-30 31-40 Other… Enter other… Was offender using drugs and/or alcohol at the time of assault? Alcohol Drugs Don't know Check all that apply. If yes, was offender feel pressured to consume or use? Yes No Don't know Follow-up Does the assaulted person plan to seek legal or college's disciplinary action against the offenders? Yes, inside the college through judicial affairs Yes, inside the college through residence halls Yes, outside the college No Don't know What resources has this person utilized thus far? Student affairs Medical Campus health service Police University police Religious organizations Campus ministries Department office/academic unit Residence hall staff Advising office Judicial affairs Personnel office Other… Enter other… Has the assaulted person been advised of campus medical, counseling, academic, residential, and disciplinary support actions? Yes No Don't know Person making report Name Address Telephone Notes/comments/description of offender Leave this field blank
You must have JavaScript enabled to use this form. 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. Date of report Date of assault Time of assault Location of assault Victim's information Sex Male Female Transgender Affiliation to college None Undergraduate student Staff Graduate student Professional student Faculty Other… Enter other… Residence Campus residence halls Off-campus - with family Off-campus - other Racial ethnicity Caucasian Latino/Hispanic Middle Eastern African Caribbean South Asian East Asian Mixed Other… Enter other… Information on the Assault Type of Coercion/Force Verbal Physical Abduction Presence of weapon Other… Enter other… Reported assault Sexual assault (verbal) Completed rape (vaginal) Completed rape (anal) Sexual assault (physical) Attempted rape Check all that apply. Place of assault Victim's home Residence hall Offender's home Outdoors Workplace Parking lot Public campus facility Car/vehicle Other campus property Other… Enter other… Was the victim using drugs and/or alcohol at the time of assault? Alcohol Drugs Check all that apply. If yes, did he or she feel pressured to consume or use? Yes No Offender's information Number of offender(s) Affiliation to college Undergraduate student Multiple offenders Students of different affiliations Graduate student Professional student Faculty Staff Not affiliated Other… Enter other… Sex of offender(s) Male Female Multiple males Multiple females Male(s) and female(s) Residence of offenders Campus residence halls Off-campus - with family Off-campus - other Unknowin Racial ethnicity Caucasian Latino/Hispanic Middle Eastern African Caribbean South Asian East Asian Mixed Other… Enter other… Offender's relationship to victim Offender's relationship to victim - None -Partner/loverEx-partner/loverSpouseAcquaintanceMet same day, sociallyMet same day, non-sociallyStrangerStudentColleague-co-workerFaculty/teaching assistantStaffOther… Enter other… Age(s) of offender(s) at the time of assault 13-19 20-25 26-30 31-40 Other… Enter other… Was offender using drugs and/or alcohol at the time of assault? Alcohol Drugs Don't know Check all that apply. If yes, was offender feel pressured to consume or use? Yes No Don't know Follow-up Does the assaulted person plan to seek legal or college's disciplinary action against the offenders? Yes, inside the college through judicial affairs Yes, inside the college through residence halls Yes, outside the college No Don't know What resources has this person utilized thus far? Student affairs Medical Campus health service Police University police Religious organizations Campus ministries Department office/academic unit Residence hall staff Advising office Judicial affairs Personnel office Other… Enter other… Has the assaulted person been advised of campus medical, counseling, academic, residential, and disciplinary support actions? Yes No Don't know Person making report Name Address Telephone Notes/comments/description of offender Leave this field blank
