Portland State University Sexual Assault Anonymous Report Form
Portland State University strongly encourage all survivors of sexual assault to access any or all of the resources listed on our sexual assault website: www.pdx.edu/sexual-assault.

This form is anonymous and confidential. The form will be sent to PSU’s Campus Public Safety and Equity & Compliance. Completing this form does NOT constitute a police report or a student conduct report. The information on this form will be used on the PSU’s annual Campus Security Report submitted to the Department of Education in compliance with the Clery Act.

PSU students have several reporting options available to them to report sexual assault or other sex offenses. These options are available any time, and can be pursued individually or simultaneously. An Interpersonal Violence (IPV) Advocate can help talk through your options and can accompany you through the process of accessing any of these reporting services:

- Interpersonal Violence Advocate (503) 725-5672
- Campus Public Safety (503) 725-4404
- Portland Police Bureau 9-1-1 or (503) 823-3333
- Dean of Student Life: Student Code of Conduct Complaint (503) 725-4422
- Office of Equity and Compliance (503) 725-5919
- Title IX Coordinator (503) 725-5919

If you have any questions about this form please call the IPV Advocate at 503-725-5672.

Reporting Information
Completing this anonymous report form does NOT constitute a police report or a student conduct report. Portland State University strongly encourage all survivors of sexual assault to access any or all of the resources listed on our sexual assault website: www.pdx.edu/sexual-assault.
Have you reported this sexual assault to law enforcement or a PSU Campus Authority?
This question assists in not double counting reports.
Required
Who is filling out this form?
Your identity is anonymous and you will not be asked to submit your name or contact information.
Questions About The Sexual Assault
When, Where and What - The sexual assault anonymous report is used to gather and record information regarding the incidence of sexual assault on and around our campus, and to inform the community about the campus climate.
When did the incident take place?
Provide an approximate date of the assault.
MM
/
DD
/
YYYY
Where did the incident take place?
Where did the assault happen? (check all that apply)
Required
What happened during the incident?
(check all that apply)
Required
Did this incident involve domestic violence, dating violence, or stalking?
(check all that apply)
Required
Additional Incident Details
Please put any additional details here.
Your answer
FOLLOW UP
For additional assistance, please contact the PSU Interpersonal Violence Advocate (503) 725-5672. The IPV Advocate serves students of all genders.
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