Reporter's name:
Position/Dept:
Phone:
Date of Report:
Victim's age:
Victim's academic year:
Victim's Gender
Date of incident:
Time of incident:
Occurred on campus?	Yes No
If on campus:	Gorham
	Portland
	Portland Hall
	LAC
Where on campus did the assault occur?

Describe assault (check one):
	sexual contact (fondling, kissing, petting but not penetration) without consent
	attempted intercourse without consent (penetration did not occur)
	intercourse (oral, anal, or vaginal penetration by penis or other object) without consent
	other, describe:

Was the absence of consent due to the victim being incapacitated by:
a) alcohol?	yes no
b) other drugs?	yes no

Describe the kind of pressure or force used by the assailant:
	none
	verbal pressure or arguments
	position of authority (boss, teacher, supervisor, etc.)
	threat of physical force (threatened to hit, hold or otherwise injur)
	actual use of physical force (hit, held victim down, twisted arm, etc.)
	gave victim alcohol or drugs so victim was significantly imcapacitated

Was a weapon involved in the assault?:	yes no
Number of assailants:
If a single assailant, describe:
gender:
race:
age:
height:
weight:
Role of assailant(s) on campus:
	student		other
	faculty		no campus role
	staff

If single assailant, describe nature of relationship with victim prior to the incident (check one):
	stranger		spontaneous date
	planned first date		relative
	friend or non-romantic acquaintance of any age
	romantic acquaintance or on-going date

Name of alleged assailant(s):

Other contact points or departments the victim reported this assault to:
	Sexual Assault Programs Manager		University Health Services
	Residence Life (P/G)		USM Police
	Counseling Center		Women's Center
	Faculty or Staff Member		Sexual Assault Response Svcs
	Other

Name of alleged victim (Optional, at the victim's choice):
Does the victim wish to be contacted by the Sexual Assault Programs Manager, Jim Daniels? yes no
Additional Comments: