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Fredonia Police Dept.
9 Church Street
Fredonia, NY 14063
Phone: 716-679-1531
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Sexual Assault Anonymous Report - Fredonia Police Department


This form is for reporting a sexual assault anonymously to the Fredonia Police. The information helps the Fredonia Police Department to better respond to victims of sexual assault. Filing this form will not result in an investigation. A person who has been assaulted may fill out this form himself or herself, or may ask a third party (such as a friend or a counselor) to do so.

Information on Victim/Survivor
Gender: Male Female
 
Age:  
 

Information on the Assault
Date of Assault:  (i.e., 8/27/08)  
 
Time of Assault:  (i.e., 10:00)   am pm
 
Type of Coercion/Force:   (Check all that apply)
Verbal
Physical
Abduction
Weapon
0ther
 
Type of Assault:   (Check all that apply)
 
Completed assault  (Penetration by penis, finger or object)
Oral
Anal
Vaginal
 
Attempted assault  (Attempted penetration by penis, finger or object)
Oral
Anal
Vaginal
 
Where was the victim when he/she first encountered the offender?
Victim's place of residence
Offender's place of residence
Residence Hall
Business Establishment
Off-campus
Outdoors
Workplace
Parking Lot
Car/Vehicle
Campus building other than a residence hall
Other
 
Place of Assault:   (Check all that apply)
Victim's place of residence
Offender's place of residence
Residence Hall
Business Establishment
Off-campus
Outdoors
Workplace
Parking Lot
Car/Vehicle
Campus building other than a residence hall
Other
 
Was the person who was assaulted using drugs and/or alcohol at the time of assault?
Alcohol: Yes No Don't Know
Drugs: Yes No Don't Know
 
If yes, did he or she feel pressured to consume or use?
Yes No Don't know
 
Is there any reason to suspect that a predatory drug (also known as date rape drugs) were used?
Yes No Unknown
 
If yes, why?


Information on the Offenders
Number of Offender(s):
1 2-3 4-5 5 or more
 
Sex of Offender(s):
Male
Female
Multiple Males
Multiple Females
Males and Females
 
Race/Ethnicity of Offender(s):
Asian
Native American
Black
Various Races/Ethnicities
Hispanic
White
Unknown
 
Affiliation to :  (if known)
Student
Faculty
Staff
Not Affiliated
 
If there were multiple offenders, did they have a connection to each other (housemates, roommates, same fraternity, same sports team)?
Yes No Don't know
 
If yes, what is the nature of their relationship?

 
Residence of Offender(s):  (if known)
Fredonia
Dunkirk
With Family
Residence Hall
Other
 
Age of Offender (estimated) at Time of Assault:
 
If Single Offender:
13-19 20-25 26-30 31-40 Other
 
If Multiple Offenders:
13-19 20-25 26-30 31-40 Other
 
Offender's Relationship to the person assaulted:   (Check all that apply)
Current Partner/Lover
Acquaintance
Ex-Partner/Ex-Lover
Met same day, socially
Spouse
Met same day, non-socially
Stranger
Colleague/Co-worker
Faculty
Staff
Student
Other
 
Was offender using drugs and/or alcohol at time of assault?
Alcohol: Yes No Don't know
Drugs: Yes No Don't know
 

Follow-Up
Does the assaulted person plan to seek legal or disciplinary action against the offenders?
 
Yes, inside through:
Fredonia Police
Judicial Affairs
Residence Halls
 
Yes, outside through:
Village of Fredonia Police
Dunkirk Police
Other Police Agency
 
No legal action
 
Don't know
 
Undecided
  



 
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