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Sexual Misconduct Incident Report

This form is for reporting a sexual misconduct to the Radford University Substance Abuse and Violence Education Support (SAVES) Office to assist with the completion of statistical records for assaults that occur to Radford University students, on- and off-campus. Filing this form will not result in an investigation, but is intended to convey needed information to assist the university in addressing the issues of sexual assault. Information contained on this form will remain confidential and will only be used in non-identifying ways.

When you submit this form, it is transmitted to the coordinator of SAVES.

Reporter's Contact Information

 
 
 
 
 
 

Victim/Survivor Information

 
 
 
 Off-campus
 On-campus
 
 White
 Black
 Asian
 Hispanic
 Middle Eastern
 Native American
 Other
 Unknown
 
 Sight
 Hearing
 Mental
 Physical
 None
 Unknown
 
 Female
 Male
 Unknown
 
 Student
 Faculty
 Staff
 None
 Other

Please describe the incident. Check all that apply.

Sexual Misconduct Information

 
 Rape (sexual intercourse against the will by force, threat, or intimidation
 Forced sodomy (anal intercourse)
 Forced oral copulation (oral-genital contact)
 Forced sexual penetration by a foreign object, including a finger
 Sexual battery (forced touching of intimate parts, fondling, kissing, but not penetration)
 Sexual harassment
 Attempts of any of the above
 

Type of Coercion/Forced Involved

Please describe the type of coercion or forced involved in the incident. Check all that apply.

 
 Verbal pressure, arguments, or disregarding victim's lack of consent
 Stalking
 Position of authority (teacher, supervisor, etc.)
 Threat of physical force (threatened to hit, held down, or otherwise injure)
 Actually used physical force (hit, held down, hurt, etc.)
 Presence of weapon
 

Was the victim/survivor signicantly incapacitated? If so, in what way?

 
 Alcohol
 Other drugs
 Sleep
 Disability
 Other
 
 On-campus
 Off-campus
 
 
 Victim's residence
 Assailant's residence
 Other campus facility
 Outdoors
 Vehicle
 Workplace
 Parking lot
 Other

Describe the nature of the relationship between the victim/survivor and the assailant(s) prior to the assault.

 
 Former romantic relationship
 Stranger
 Relative
 Study partner
 Planned date
 On-going romantic relationship
 Friend or non-romantic acquaintance
 Impromptu date (met at party or bar)

Assailant Information

 
 
 On-campus
 Off-campus
 Unknown
 
 White
 Black
 Asian
 Hispanic
 Middle Eastern
 Native American
 Other
 Unknown
 
 Sight
 Hearing
 Mental
 Physical
 None
 Unknown
 
 Male
 Female
 Unknown
 
 Student
 Faculty
 Staff
 None
 Unknown

Contacts and Services

The victim/survivor has reported the assault to:

 
 SAVES office
 Residence life (RA or RD)
 University police
 Local police
 Local hospital
 Women's resource center
 Dean of Students
 Student Counseling Services
 Student Health Services
 Faculty or staff member
*