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University of Pittsburgh at Johnstown Sexual Assault Anonymous (University of Pittsburgh at Johnstown)

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University of Pittsburgh at Johnstown
Sexual Assault Anonymous Reporting Form
Read and complete the form and send to:
Pitt-Johnstown Chief of Police – Campus Police Suite, Physical Plant Building, Johnstown, PA 15904
Read this before completing the form:
This form
is intended for the anonymous and confidential reporting of sexual assault and rape.
This form
was designed to allow survivors of sexual violence – as well as others with whom they discuss these
incidents – to bring the misconduct to the attention of the University. Data collected from this form will help us
better understand the extent of the problem, plan more effective prevention and response efforts, and create a safer
campus community.
The form is one option for reporting sexual assault or rape. Completion of this form does not initiate a police
investigation or judicial action. However, if it is determined that there is an ongoing threat to the campus
community the University is obligated to investigate such incidents, especially those involving weapons or multiple
alleged victims. Survivors who complete this form may choose whether or not they also wish to file a police report
or pursue judicial action.
Anyone can s
ubmit a form on behalf of themselves or a survivor. The form should only be completed with
the knowledge and permission of the survivor. Only information reported by the survivor, resources
provided to the survivor, and behavior observed in the survivor should be reported on this form. This form
is not intended as a checklist to interview the survivor.
Prior to
completing the form, please note that the form:
• May be submitted anonymously
• Will be held in the strictest confidence possible. All information contained on this form will be
kept confidential except in the case of an ongoing threat to the community that the University is
obligated to address. All efforts will be made to protect the survivor’s anonymity; no information
should be included which might identify the survivor unless explicitly requested by the survivor.
• Will be used in the compilation of statistical reports in compliance with federal law.
Student health and safety are primary concerns of the University of Pittsburgh at Johnstown. Sexual assault and
rape are crimes of violence and control, using sex acts as a weapon. Many on and off-campus resources are
available to assist survivors of sexual assault and rape. We strongly encourage all survivors to seek help.
This is NOT
a police report.
To file a police report, contact the Pitt-Johnstown Police Department at 814-269-7005
Anonymous Reporting Form 1
Today’s Date:
PLEASE SELECT WHICH BEST DESCRIBES YOU
I have been sexually assaulted/raped and I am looking for information and resources.
I am helping someone who has been sexually assaulted/raped.
ABOUT THE SURVIVOR
Gender:
Race:
Age at time of assau
lt:
If survivor is a student, year in school:
Residence:
ABOUT THE OFFENDER(S)
(I.e. person or persons who committed the assault)
Offender was:
University Affiliation:
Student Faculty Staff
Alumni
Not Affiliated
(If multiple offenders, check all that apply)
Unknown Other
Residence:
(If multiple offenders, check all that apply)
Offender’s relationship to the survivor:
Partner or Lover
Ex-partner, Ex-spouse, Ex-lover
Spouse
(Check all that apply)
Faculty member
Colleague or co-worker
Stranger
Acquaintance
Met same day
Work supervisor
Other
Anonymous Reporting Form 2
Current age:
Current Univeristy Affiliation:
On Campus
Off Campus Unknown
-
-
-
-
-
ABOUT THE ASSAULT
Date of Assaul
t:
Time:
(If exact time is unknown, enter best approximation)
Location of Assault:
Description of
specific location where assault occurred:
Verbal pressure or arguments
Threat of physical force
Use of weapon (s)
If Coercion/Force
Used: (Check all that
apply)
Position of authority (employer, staff, faculty, etc.)
Use of physical force
Other
Was alcohol or other drugs involved?
The survivor used alcohol:
The offender(s) used alcohol:
Does the survivor suspect that they were drugged involuntarily?
Was drug testing done?
Description of the incident:
Anonymous Reporting Form 3
None
The survivor used other drugs:
The offender(s) used other drugs
-
-
-
-
INTERVENTION & FOLLOW-UP
Is this the first time the survivor is reporting this to the University?
As a result of the assault, the survivor has already acquired assistance from or used the
following resources (check all that apply)
Campus Resources
Off Campus Resources
Police department/law enforcement
Did the survivor receive m
edical treatment as a result of the assault?
Does the survivor plan to take action against the offender(s)?
If yes, check all actions planned:
Office of Student Con–uct
Please check options provided below:
Referred to the following Campus Resources:
Office of Student Conduct – 814-269-7062
Referred to the following Off Campus Resources:
Hospital or other health care facility
Women’s Help Center – 800-999-7406
Con
emaugh Hospital – 814-534-9000
Windber Hospital – 814-467-3000
Other
Health and Counseling Services – 814-269-7119
Campus Police – 814-269-7005
Housing and Residence Life – 814-269-7115
Office of Student Conduct – 814-269-7062
Other
Hospital or other health care
Victim Services, Inc. – 800-755-1983
Women’s Help Center – 800-999-7406
Office of Equity and Inclusion – 814-269-7070
Mental health provider or facility
Other
Campus Police –814-269-7005
Other law enPorement agency
An
on
y
mous Report
Other
Health and Counceling Services 814-269-7119
Was sexual assault evidence collected?
Campus Police 814-269-7005
Housing and Residence Life 814-269-7115
Office of Equity and Inclusion 814-269-7070
Mental health provider
Victim Services, Inc - 800-755-1983
-
-
-
-
Provided other forms of support:
Provided educational
material
Helped contact family or friend
Other
Suggested Supportive Comments:
(
Check all that apply)
ABOUT THE PERSON COMPLETING THIS FORM
Current U
niversity Affiliation:
Other Infor
mation You Believe Maybe Relevant:
Anonymous Reporting Form 5
Encouraged survivor to seek medical attention
Encouraged survivor to seek counseling if they
haven’t yet
Told survivor it wasn’t her/his fault
Told survivor tThat you were glad they told you
Told survivor they have a lot of courage to come forward
Encouraged survivor to seek support from
friends, family and/or other outside agencies
-
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University of Pittsburgh at Johnstown Sexual Assault Anonymous (University of Pittsburgh at Johnstown)

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Completed 30 August 2020

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