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Sexual Assault Survey Form

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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.

Offender Details
How many offenders were involved?

Offender 1 Details
Surname of Offender? (if known)
Given names of Offender? (if known)
Alias(es) (Nicknames, names used etc.)
Gender	Male Female Unknown
Date of Birth
Age (or best estimate)
Place of Birth
Offender's residential address at time of offence (if known)
Offender's current residential address (if known)

Offender's contact number/s		Unknown
	Email
	Mobile
	Phone
	Relative
	Friend
	Other

Offender 1 Identification
The following questions relate to the OFFENDERS description (at the time of the assault)

Offender 2 Details
Surname of Offender? (if known)
Given names of Offender? (if known)
Alias(es) (Nicknames, names used etc.)
Gender	Male Female Unknown
Date of Birth
Age (or best estimate)
Place of Birth
Offender's residential address at time of offence (if known)
Offender's current residential address (if known)

Offender's contact number/s		Unknown
	Email
	Mobile
	Phone
	Relative
	Friend
	Other

Offender 2 Identification
The following questions relate to the OFFENDERS description (at the time of the assault)

Offender 3 Details
Surname of Offender? (if known)
Given names of Offender? (if known)
Alias(es) (Nicknames, names used etc.)
Gender	Male Female Unknown
Date of Birth
Age (or best estimate)
Place of Birth
Offender's residential address at time of offence (if known)
Offender's current residential address (if known)

Offender's contact number/s		Unknown
	Email
	Mobile
	Phone
	Relative
	Friend
	Other

Offender 3 Identification
The following questions relate to the OFFENDERS description (at the time of the assault)

Offender 4 Details
Surname of Offender? (if known)
Given names of Offender? (if known)
Alias(es) (Nicknames, names used etc.)
Gender	Male Female Unknown
Date of Birth
Age (or best estimate)
Place of Birth
Offender's residential address at time of offence (if known)
Offender's current residential address (if known)

Offender's contact number/s		Unknown
	Email
	Mobile
	Phone
	Relative
	Friend
	Other

Offender 4 Identification
The following questions relate to the OFFENDERS description (at the time of the assault)

Offender 5 Details
Surname of Offender? (if known)
Given names of Offender? (if known)
Alias(es) (Nicknames, names used etc.)
Gender	Male Female Unknown
Date of Birth
Age (or best estimate)
Place of Birth
Offender's residential address at time of offence (if known)
Offender's current residential address (if known)

Offender's contact number/s		Unknown
	Email
	Mobile
	Phone
	Relative
	Friend
	Other

Offender 5 Identification
The following questions relate to the OFFENDERS description (at the time of the assault)

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
Please retype the characters *

Thank you for taking the time to complete this form

Last updated July 2012