Name of CSA:
CSA Position Title Office:
CSA Phone:
CSA Email:
Be sure to ask the victim the following questions and document the response.
Do you want to contact the police and have this matter investigated by law enforcement?
Do you want to be identified to law enforcement?
Yes No If the victim answers yes to either question, call the police and provide the victim's contact info.
Date & Time of Incident:
Date & Time Reported to CSA:
Incident Crime Type:
Victim Affiliation:
Suspect Affiliation:
Additional Party Bystander:
Description of Incident Crime (as detailed as possible):
Rape unlawful vaginal penetration with a penis:
Sodomy unlawful anal penetration with a penis:
Foreign Object Penetration unlawful vaginal or anal penetration with a object, including fingers
Oral Copulation unlawful contact between mouth and genitals or anus
Fondling unlawful touching of the breasts, buttocks, or genitals
Statutory Rape sex between a person over the age of 18 and a person under the age of 18
Incest sex between persons related within the degrees wherein marriage is prohibited by law
Was the crime committed forcibly, against the victim's will?
Was the victim incapable of giving consent because the victim is below legal age of consent?
Was the victim incapable of giving consent due to mental or physical impairment, including under the influence of drugs or alcohol, and this was or should have been known to the assailant at the time?
Is there evidence that the assault was facilitated by the intentional administration of drugs or alcohol by the assailant or by another with the assailant's knowledge? If Yes, describe below.
Location of Incident/Crime (Building name, address)
.
Location Details
Is there evidence that this incident was motivated by hate or bias?
If Yes, identify the potential protected class or classes targeted and describe evidence and statements made below.
OTHER REPORTING - Have you reported this incident to other departments or agencies? List names and dates.