MIT Police

Form for Anonymous Reporting of Sexual Assault to the MIT Police Department

This form is for reporting a sexual assault anonymously to the MIT Police Department. A person who has been assaulted may complete this form himself or herself and send it to the MIT Police Department, or s/he may ask a third party (such as a friend or counselor) to do so.

The MIT Police may use this information to determine whether MIT has a legal requirement to issue a timely warning to the MIT community, to assist with legally required statistical record keeping and to respond to any other legal obligation.

In completing the form, while more information is better for MIT police purposes, you do not need to complete all questions.

The MIT Police Department is located at W89, 301 Vassar Street, Cambridge, MA.

For information on resources and options:

1. Date of Report: Time:
2. Date of Assault: Time:
Information on Victim/Survivor
3. Sex: Female Male Trans*
4. Age: 5. National Origin (if known):
6. Affiliation to MIT: Undergraduate
Graduate Student
Faculty
Staff
Not Affiliated with MIT
Other
7. Residence: Dormitory
Fraternity/Sorority/ILG
Off-campus
Information on the Assault
8. Lack of Consent
(Check all that apply)
Lack of consent
Physical intimidation/restraint
Presence of Weapon
Verbal threat(s)
Other
9. Reported Assault
(Check all that apply)
Completed Rape:
Oral
Anal
Vaginal
Indecent Assault (fondling, groping)
Intent to Commit Rape
(Actual touching, without consent, with intent to commit rape)
Statutory Rape
10. Place of Assault
(Check all that apply)
On-campus
Off-campus
Victim's Home
Offenders' Home
Dormitory
MIT Fraternity
MIT Sorority
Independent Living Group
Workplace
Campus Facility
Parking Lot
Parking Garage
Car/Vehicle
Outdoors
On public property adjacent to MIT campus
(e.g., Cambridge street sidewalk, Kendall T stop)
11. Does the victim/survivor suspect that s/he may have been given a date rape narcotic (e.g., Rohypnol (a "Roofie", Ketamine, GHB. etc.) prior to the assault? Yes No Unknown
12. Was the victim/survivor under the influence of alcohol or drugs at the time of the assault? Yes No Unknown

If "Yes", did victim/survivor feel pressured to consume or use?
Yes No Unknown
Information on the Offenders
13. Number of Offender(s)
14. Sex of Offender(s) Female
Male
Trans*
Multiple Females
Males and Females
Multiple Males
Unknown
15. Affiliation to Institute: Undergraduate Student
Graduate Student
Faculty
Staff
Multiple Offenders of Different Affiliations
Not Affiliated
Unknown
Other
16. Residence of Offender(s) Dormitory
Fraternity/Sorority/ILG
Off-campus
Unknown
17. Offender's Relationship to the Victim/Survivor: Partner/Spouse
Ex-Partner/Former Spouse
Colleague/Co-worker
Dating/Used to Date
Acquaintance
Faculty/Teaching Assistant
Stranger
Other
Follow-Up
18. Does the victim/survivor plan to seek criminal, legal or MIT disciplinary action against the offender(s)? Yes, from MIT
Yes, assistance from outside MIT
No
Unknown
NOTE: Completion of this form does not preclude you from filing a formal complaint at a later date.
19. What resources has the person utilized thus far? Deans' Offices Undergraduate Education (DUE), Graduate Education (ODGE) and Student Life (DSL)
Medical (Counselors, Psychologists, Health Ed, Physicians, Nurses, EMTs)
MIT Police Investigations Unit
Religious Counselors
Human Resources
Department Office
Housemaster, Graduate Resident Tutor, RLAD and/or RA in FSILG
Dean on Call
Violence Prevention & Response (VPR) advocate
Title IX Coordinator
Student Support Services
Other