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Sexual Assault Data Collection Form

The pertinent sections of this form should be completed by any Community College of Rhode Island professional staff member who has contact with a victim of sexual assault. The purpose of this form is to collect aggregate data, monitor service usage, and detect trends.

The victim's name should not be reported. Please complete the form after discussion with the victim. Please complete as many of the questions as possible. If the victim does not or cannot recall the details of the event or if she/he refuses to provide an answer, please check the "unknown" box.

Please submit a supplemental report if additional or changed information comes to your immediate attention.

Report Information
Incident Description
Drugs and Alcohol
Additional information about the victim
Alleged Assailant Information