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:

______ Counseling Center

______ Housing and Residential Life

______ Student Justice

______ Student Health Service

______ Hospital

______ Sexual Assault Victims Services