CONFIDENTIAL

INDIVIDUAL UWL REPORT FORM
Print, complete, and submit to 149 Graff Main Hall

Please check one: __Sexual Assault  __Domestic Violence  __ Dating Violence __ Stalking 

(For incidents of stalking, please complete the comment area below and specify dates and occurrences.)

(Optional)   Initial of Victim's First Name:   ______  
 (This information is requested to ascertain accuracy of numbers reported, not for identification purposes.)

Date of Assault:  _________       Time of Assault:  ________       Date Reported to You:  __________       

*Sexual Assault Degree:  _____  First    _____  Second    _____  Third    _____  Fourth

Number of Perpetrators:  ______

Perpetrator was:           _____ UWL Student                        _____ Student from another UW institution

(check all that apply) _____ UWL Employee                    _____ Student from outside the UW system

                                    _____ Non-Student                         _____ Stranger/Not acquainted with victim

                                    _____ Known to victim

Assault was:                 _____ male to female                       _____ male to male

                                    _____ female to female         _____ female to male

Victim reported:            _____ to police                                _____ to UWL Student Life Office

(check all that apply)     _____ to another campus office (please specify: __________________)

                                    _____ to no one                               _____ other (please specify: ____________)

**Location:                  _____ on campus          _____ in a UW-L residence hall          _____  non-campus

_____ public property              _____ other (specify ______________________)

Alcohol/drugs involved -- perpetrator:            _____ yes           _____ no         _____ don’t know

Alcohol/drugs involved -- victim:                       _____ yes       _____ no         _____ don’t know

(Please note that the above information regarding alcohol/drugs is requested by UW-System.)

Other comments: __________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________
________________________________________________________________________________

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Submitted by: _____________________________________________________________________

Office: ___________________________________________________________________________

Date: ____________________________________________________________________________

Submit form to Student Life Office, 149 Graff Main Hall.  This form will not be submitted to any other office, although data totals may be used for semester and annual reports to increase awareness of this issue at UW-La Crosse.  Comprehensive data reports will respect individual confidentiality by not linking any information to a particular assault report. 

*Legal Definitions of Sexual Assault in the State of Wisconsin
First Degree Sexual Assault: Whoever does ANY of the following is guilty of a Class B felony.
(a) Has sexual contact or sexual intercourse with another person without consent of that person and causes pregnancy or great bodily harm to that person;
(b) Has another person use of a dangerous weapon or any article fashioned in a manner to lead the victim reasonably to believe it to be a dangerous weapon;
(c) Is aided or abetted by one or more persons and has sexual contact or sexual intercourse with another person without consent of that person by use or threat of force or violence. 

Second Degree Sexual Assault: Whoever does ANY of the following is guilty of a Class C felony.
(a) Has sexual contact or sexual intercourse with another person without consent of that person by use or threat of force or violence; 
(b) Has sexual contact or sexual intercourse with another person without consent of that person and causes injury, illness, disease, impairment of sexual or reproductive organ, or mental anguish requiring psychiatric care for the victim;
(c) Has sexual contact or sexual intercourse with a person who suffers from a mental illness or deficiency which renders that person temporarily or permanently incapable of appraising the person's conduct, and the defendant knows of such condition;
(cm) Has sexual contact or sexual intercourse with a person who is under the influence of an intoxicant to a degree which renders that person incapable of giving consent if the defendant has actual knowledge that the person is incapable of giving consent and has the purpose to have sexual contact or sexual intercourse with the person while the person is incapable of giving consent;

(d) Has sexual contact or sexual intercourse with a person who the defendant knows is unconscious;
(f) Is aided or abetted by one or more other persons and has sexual contact or sexual intercourse with another person without the consent of that person.

Third Degree Sexual Assault is sexual intercourse with a person accomplished without the consent of that person.  Third degree assault is a Class G felony.

Fourth Degree Sexual Assault is any sexual contact with a person without the consent of that person.  Fourth degree sexual assault is a Class A misdemeanor.

**Location of Assault Definitions
On campus: (a) any building or property owned or controlled by an institution of higher education within the same reasonably contiguous geographic area of the institution and used by the institution in direct support of, or in a manner related to, the institution's educational purposes, including residence halls; and (b) property within the same reasonably contiguous geographic area of the institution that is owned by the institution but controlled by another person, is used by students, and supports institutional purposes (such as a food or other retail vendor).

Non-campus: (a) any building or property owned or controlled by a student organization recognized by the institution; and (b) any building or property (other than a branch campus) owned or controlled by an institution of higher education that is used in direct support of, or in relation to, the institution's educational purposes, is used by students, and is not within the same reasonably contiguous geographic area of the institution.

Public property: All public property that is within the same reasonably contiguous geographic area of the institution, such as a sidewalk, a street, other thoroughfare, or parking facility, and is adjacent to a facility owned or controlled by the institution if the facility is used by the institution in direct support of, or in a manner related to the institution's educational purposes.

Other: Although it is not required by UW System to report those assaults that took place in any other geographic areas than those outlined above, the Student Life Office would like to continue gathering statistics for any assault that is reported – please be as specific as possible regarding location.