University of North Carolina at Chapel Hill Confidential Report (Blind Report) Incident of Sexual Assault Directions: The person filling out this report should place the completed form in the drop box or send to the Office of the Dean of Students, CB# 5100, Suite 1106 SASB North. Please fill out as much information as you feel comfortable providing.
1. Type of incident (check all that apply) rape
attempted rape
other sexual invasion (ex. groping, flashing)
alcohol / drug assisted (please circle which)
other (please specify)____________________ ______________________________________
2. Location of incident on campus
off campus – local (Chapel Hill/Carrboro)
off campus (other)
please specify (if possible)_____________________________________________________
3. Date of incident: _____/_____/_____
time:
4. Was the incident reported to law enforcement? No
University Police
Chapel Hill/Carrboro
5. Year in school: _______________ 6. Gender identification: ______________
7. Date of report: _____/_____/_____
Continued on back
Other (please specify) __________________ __________________
8. Would it be okay for the Assistant Dean of Students to contact you to offer further information about support services and resources at UNC? Yes
No
(circle one)
If yes, please provide your name and cell phone number and/or email address:
9. Relationship with assailant: current partner
former partner
friend
acquaintance
other (please specify) ____________________ ____________________
stranger
10. Last four digits of your PID: ____________________ Note: This information is only used to ensure that we do not have “double reporting�
11. Any additional information that you wish to share:
Thank you For additional resources, please see: http://womenscenter.unc.edu/safe/