Portland State University Sexual Assault Anonymous Report Form

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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.

No, I have not reported it.

Yes (i.e. Police, Student Conduct, Women's Resource Center, Equity and Compliance, Student Group Advisor, or a Coach, etc.)

Other:

Required

Who is filling out this form? *

Your identity is anonymous and you will not be asked to submit your name or contact information.

Survivor / Victim

Friend / Acquaintance / Family Member

PSU Employee

Other:

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.

YYYY

Where did the incident take place? *

Where did the assault happen? (check all that apply)

On campus (Cramer Hall, Hoffman Hall, Millar Library, PSU Parking Structure, etc.)

Student housing (Broadway, Ondine, University Pointe, etc.)

A PSU sponsored activity or event

Public building, or adjacent to PSU (Sidewalks/Streets, etc.)

Not affiliated with PSU

Other:

Required

What happened during the incident? *

(check all that apply)

Forcible Rape: the penetration, no matter how slight, of the vagina or anus with any body part or object, or oral penetration by a sex organ of another person, without the consent of the victim.

Forcible Fondling: the touching of the private body parts of another person for the purpose of sexual gratification, without the consent of the victim, including instances where the victim is incapable of giving consent because of his/her age or because of his/her temporary or permanent mental incapacity.

Incest: non-forcible sexual intercourse between persons who are related to each other within the degrees wherein marriage is prohibited by law.

Statutory Rape: is consensual sexual intercourse with a person who is under the statutory age of consent.

Required

Did this incident involve domestic violence, dating violence, or stalking? *

(check all that apply)

Domestic Violence: violence committed by the victim's current or former spouse, current or former cohabitant, person similarly situated under domestic or family violence law, or anyone else protected under domestic or family violence law.

Dating Violence: violence by a person who has been in a romantic or intimate relationship with the victim. Whether there was such relationship will be gauged by its length, type, and frequency of interaction

Stalking: repeated, unwanted contact that would cause a reasonable person to fear for their or others' safety.

Required

Additional Incident Details

Please put any additional details here.

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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