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Emergency Phone Numbers

Crime Stoppers:

1800 333 000

Policelink:

131 444

Sexual Assault Survey Form

By completing this form you are NOT making a formal complaint to police.

Answering these questions is voluntary.
Your completeness and accuracy would be appreciated.

* indicates madatory fields

Your Details
Name (Optional)
Gender * Male
Female
Other (describe)  
Alias(es)
Date of Birth
Age
Your residential address at time of offence
Are you willing for police to contact you if required? * Yes
No
(If yes, any special instructions e.g. call after hours only, by email only)
How can we contact you?  Phone
 Mobile
   Email
 Relative
   Friend  Support Service

Date and Time of Offence
When did this assault happen? * Daylight
Darkness
  On or between (Date)  Time: (00:00 AM)
  and (Date)  Time: (00:00 AM)

Summary of Incident *
Please describe in as much detail as possible, without leaving anything out, everything that happened.

Detail is very important so write down everything that you remember about the assault, (even if you don't think it is important), everything you saw, heard, smelt, felt, any conversation, clothing, what you did, what they did, any objects or weapons involved, how you came to know the offender. This detail is very important as it allows us to analyse your information against any similar assaults. If you are finding it difficult to remember details, it may help to close your eyes and take a moment to picture the event in your mind.

How did the offender assault you? (Select ALL that apply) *
Vaginal Intercourse Anal Intercourse Fellatio
(Oral Sex)
Cunnilingus
(licked vagina)
Anilingus
(licked anus)
Digital (finger/s) penetration Masturbation Simulated intercourse Fondling Kissing
Foreign object insertion Whole fist insertion Stabbing Suffocation Whipping
Burning (describe)
Biting (describe)
Torture (describe)
Beating Slapping Kicking Choking Pinching
Hair pulling Verbal assault Cutting Strangulation Shooting
Other (describe)
Did the offender ejaculate? No
Unknown
Yes (If yes, please specify)

The following questions relate to YOUR description (at the time of the assault)
What was your general appearance? Male
Female
Your complexion? Dark
Light
Tanned
Other  
Your age at the time?
Your height?
Your build? Small/thin
Medium/Avg
Large
How long was your hair?
Did you have any unique features? crossed eyes
noticeable limp
skin disorder
dinstinctive hairstyle
deformity
other




(specify)
(specify)
(specify)
Describe yourself (eg loud, shy, withdrawn?)
What were you wearing at the time of the assault?
Did the offender take any of your clothes with them? No
Yes
If yes, please give details
Did the offender take anything else away?
 (eg drivers licence, purse, personal belongings)
What was your occupation?
Were you affected by any of the following just prior to the assault? Health issues (explain)

Mental Health (explain)

Physical Injury / disability (explain)

Alcohol/Drug (explain)

Other (explain)

Location(s) of First Meeting, Offence & Offender Details
Did you meet online?
(e.g. Social networking site, Chat room, online dating)
No
Yes (if yes explain)
Had you met the offender/s before? No
Yes (if yes explain)
Did you know the offender? No
Yes (if yes, how and for how long)
Where did you first meet the offender on the day of the offence/incident? (e.g. address, business, location)
Where did the assault / incident take place? (e.g. address) Licensed Premises

Private Residence

Other
Where did the assault/incident end? (e.g. address, business, location) As per 'Where the assault began'
Other (provide details)

Offender Details
How many offenders were involved?

General
How did you first learn about the Alternative Reporting Options (ARO) process? Police
Sexual assault service
Doctor/GP
Internet
Own research
Other (provide details)

Spam Check
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Thank you for taking the time to complete this form
Last updated July 2012