TEXAS STATE UNIVERSITY-SAN MARCOS

SEXUAL ASSAULT REPORT FORM

The purpose of this form is to aid Texas State University-San Marcos in the gathering of statistical data concerning the occurrence of sexual assault on the campus or in the vicinity of the campus. Federal law requires public universities to compile this data, to report it and make it available as required. This report will not be used as an investigative tool or in any way to identify the victim.

Reported by Date Reported to You

1. Information about Incident: Date/Time

2. How was the information provided to you?

______ 1st Hand (Directly from victim to you)

______ 2nd Hand (Staff member, roommate, or friend received information first hand and relayed it to you)

______ 3rd Hand (i.e., You overheard a conversation about the incident)

3. Location of incident:

On Campus (San Marcos) ______ If on campus, in Residence Hall?

On Campus (Round Rock)

Off-Campus (Within San Marcos City limits)

Contiguous Public Property (public lands within two blocks of San Marcos Campus)

Contiguous Public Property (public lands within two blocks of Round Rock Campus)

Other Campus Property (Texas State buildings/grounds away from the Main Campus such as Freeman Ranch, University Camp etc.)

Other Texas State System Property (describe the location, i.e. building, address, street name, etc.)

4. Relationship of the Assailant and Victim:

______ Acquaintance

______ Stranger

______ Unknown if victim and assailant were acquainted

5. Was either the victim or assailant under the influence of alcohol or other drugs?

Victim: ______ Yes ______ No ______ Unknown

Assailant: ______ Yes ______ No ______ Unknown

6. Please provide as much detail as you are able (no names needed):

7. Do you know if the victim requested an investigation? ______ Yes ______ No

If yes, by whom? ______ University Police Department

______ San Marcos Police Department

______ Round Rock Police Department

______ Other, list

8. Other Services Sought: