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Campus Security Authority Sexual Assault Reporting Form
Date of Report
Date the incident occurred
Name of campus security authority
Department and contact number
If multiple incidents were reported or if the date the incident occurred is unknown, please note below:
Reporting Person Contact Information
Reported By:
The Survivor
The Offender
A Third Party
First Name
Last Name
Phone Number
Email
If a third party (e.g.
roommate, friend, parent
) reported the crime to you, please enter the relationship of the third party to the victim:
Agencies or Offices Notified
If, to your knowledge, an outside agency or internal office was notified, please enter the name of that agency or office.
Agency/Office
Does the victim want the incident reported to law enforcement?
Yes
No
Survivor’s Information
Gender
Male
Female
Unknown
Is the survivor a Bradley University student?
Yes
No
Unknown
If yes, what is his/her year in school?
Fresh
Soph
Jr
Sr
Unknown
First Name (optional)
Last Name (optional)
Phone Number (optional)
Email (optional)
Offender's Information
Gender
Male
Female
Unknown
Is the offender a Bradley University student?
Yes
No
Unknown
If yes, what is his/her year in school?
Fresh
Soph
Jr
Sr
Unknown
First Name (optional)
Last Name (optional)
Phone Number (optional)
Email (optional)
Incident Category
Rape (except Statutory)
Incest
Fondling
Statutory Rape
Location Details
What best describes the location of the crime?
(If the crime occurred in multiple places, check all that apply.)
On-Campus Student Housing Facility (i.e. residence hall, fraternity, sorority, St. James complex, Main St. Commons)
On-Campus, not in a student housing facility (i.e. academic and/or administrative building, university grounds)
Public Property (i.e. streets and sidewalks immediately adjacent to campus)
Noncampus in a University owned, leased, or controlled space (off-campus classroom, athletic practice/game facility, university-sponsored trip)
Unknown location, other
I do not know which category this location would fall under
Incident Information
Specific location of incident
(building name, street address, room number)
Time of incident (
if known
)
Incident information provided to you.
(Please provide specific, detailed information; can attach additional document if necessary.)
The survivor and the offender were
Strangers
Acquaintances
Unknown
The survivor was under the influence of
Alcohol
Illicit drugs
Date rape drugs
The offender was under the influence of
Alcohol
Illicit drugs
Date rape drugs
