Anonymous Report Form

The purpose of this form is to allow members of the UTA Community to anonymously report incidents of dating/domestic violence. This report form is used to convey information that is needed to track the university's response to the incident being reported, as well as, to assess the danger that the incident may represent to the community at large. This form also assists in understanding the campus climate and planning a response to relationship violence. All efforts must be made to maintain the victim's anonymity; no information should be included which might identify the victim, unless the victim asks you to do so. Please return this form to the Violence Prevention Program as soon as possible, preferably within 24 hours so that timely coordination of services is assured. For any questions, please contact Deanee Moran, Response and Prevention Coordinator at 817-272-0112.

Please Note: Completing this form does NOT constitute a police report nor a student conduct report. You will not be contacted by the Violence Prevention Program Coordinator unless you indicate a desire to be contacted.

Date of report:

Time:

Information on the Victim

1. Affiliation to UTA

Undergraduate Student
Graduate Student
Faculty
Staff
Visitor
Not Affiliated
Unknown
Other

2. Where does the victim live?

Residence Hall/Dorm
UTA Apartments
Fraternity
Sorority
Off-campus
Unknown
Other

3. Gender of the Victim

Male
Female

4. Ethnicity of the Victim

White
Black
Hispanic
Asian
Native American
Other

5. Age of the Victim

Information on the Offender

6. Number of offenders

7. Gender of the offender (s):

Male
Female

8. Age of Offender(s):

9. Affiliation to UTA

Undergraduate Student
Graduate Student
Faculty
Staff
Visitor
Not Affiliated
Unknown
Other

10. Where does the offender live?

Residence Hall/Dorm
UTA Apartments
Fraternity
Sorority
Off-campus
Unknown
Other

11. Ethnicity of the Offender

White
Black
Hispanic
Asian
Native American
Other
12. Offender's relationship to the victim
Stranger
Acquaintance
Classmate
Date
Partner/Lover
Ex-partner/ex-lover
Spouse
Ex-spouse
Faculty
Staff
Colleague or co-worker
Work Supervisor
Met same day socially
Met same day non-socially
Unknown
Other
13. Was the Offender/victim drinking alcohol prior to the dating/domestic violence incident?
Yes
No
Unknown
14. Was the Offender/victim using drugs prior to the dating/domestic violence incident?
Yes
No
Unknown

Information on the Assault

15. Date of the Assault:

16. Time of the Assault:

17. Place where Assault Took Place

Residence Hall/Dorm
UTA Apartment Housing
Centennial
Sorority
Fraternity
Public Campus Facility (gym, library, other)
Academic Building
Parking Lot
Victim's Residence
Offender's Residence
Workplace
Car/Vehicle
Off campus
Outdoors
Other

18. Type of Assault

Physical
Emotional
Sexual
Threat of Violence
Other

19. Does the victim have children?

Yes
No
Unknown

20. Is the perpetrator a legal parent or guardian of the children?

Yes
No
Unknown

21. Is there a restraining order in place?

Yes
No
Unknown

22. Please provide a brief description of the dating/domestic violence incident?

Follow Up Information

23. To your knowledge, has this incident been reported to the Response and Prevention Coordinator, the UTA Police or to Student Affairs?

Yes
No
Unknown
24. If the victim has not reported, to your knowledge, what were the reasons for not reporting?

25. To your knowledge, what resources has the victim utilized thus far?

Response and Prevention Coordinator
Counseling and/or Mental Health Services
Student Health Services
Dean of Students
UTA Police
Women's Center Of Tarrant County Safe Haven
Affirmative Action
Other

Information about the Person Completing this form

26. I am the

victim
Witness or observer
Faculty or staff person
Roommate or housemate
Family member
Partner
Other

If you would like additional information related to dating/domestic violence or if you would like to be contacted by the Response and Prevention Coordinator on campus, please check the box below and fill out the following information. You DO NOT have to complete this section. It is simply a resource to help you through this traumatic event if you so desire.

27. Would you like to be contacted by the Response and Prevention Coordinator

Yes
No

28. If so, please provide the following contact information (you may use your first name only if you wish)

Name
Phone Number
E-mail address