SEXUAL ASSAULT REPORTING FORM
UNIVERSITY OF WISCONSIN-WHITEWATER
DEAN OF STUDENTS OFFICE
□
□
THE ASSAULT TOOK PLACE ON CAMPUS OR PROPERTY ADJACENT TO CAMPUS (any time, non-student or student)
and you have witnessed the assault or spoken with the victim or offender (first-hand report)
A UWW STUDENT REPORTED AN ASSAULT THAT OCCURRED DURING THEIR COLLEGE YEARS (any college, any
location) and you have witnessed the assault or spoken with the victim or offender (first-hand report)
IF EITHER OF THESE TWO BOXES IS CHECKED, PLEASE PROCEED WITH COMPLETING THE REPORT.
Victim Name (optional)
Requested confidentiality
Phone #
Yes
□
No
Campus email:
□
Date of assault:
Time of assault:
Location of assault:
On-campus:
(example: Winther Hall parking lot, Res Hall, UC, etc.)
□
Off-campus, in City of Whitewater:
□
Other (Off-campus, outside City of Whitewater):
□
□
unknown □
Contiguous Public Property (such as streets, sidewalks, etc. adjacent to University property):
Relationship of victim to offender:
acquaintance*
□
not an acquaintance
□
*an acquaintance is someone the victim would define as “not a stranger”
----------------------------------------------------------------------------------------------------------------------------- ------------------------------------Please check all that apply (as of today’s date)
Victim: Gender: _____
Age: _____
UWW Student:
□
UWW Employee:
Offender: Gender: _____
□
Student at other UW Institution:
□
Nonstudent:
□
Age: _____
□
□
□
□
□
UWW Student:
UWW Employee:
Student at other UW Institution:
Nonstudent:
Unknown:
---------------------------------------------------------------------------------------------------------------------------------- --------------------------------
□
Offender: Yes □
Was alcohol and/or other substance involved? Victim:
Was alcohol and/or other substance involved?
Yes
List substance: ________________
List substance: ________________
□
No □
No
□
Unknown □
Unknown
If weapon involved, type of weapon: ________________________ If injury sustained, type of injury:
Did victim receive medical care? Yes
□
No
□
Location: ____________________________________________________
----------------------------------------------------------------------------------------------------------------------------- -----------------------------------Description of incident:
THE FORM CONTINUES ON THE OTHER SIDE............
Sexual Assault: Section 940.225 of the Wisconsin Statutes creates four degrees of sexual assault. The degrees are based upon the
amount of force used by the assailant and the harm done to the victim. First, second and third degree sexual assaults are felonies;
fourth degree sexual assault is a misdemeanor.
Degree of Sexual Assault Committed (PLEASE SELECT ONE)

First degree sexual assault includes:
Sexual intercourse or sexual contact without consent which causes pregnancy or inflicts great bodily harm, or sexual
intercourse or sexual contact without consent accomplished by using or threatening to use a dangerous weapon, or
sexual intercourse or sexual contact without consent while aided by one or more persons.
A person can be imprisoned not more than twenty years for committing first degree sexual assault.

Second degree sexual assault includes:
Sexual intercourse or sexual contact without consent through the use or threat of violence, or sexual intercourse or sexual
contact without consent which causes injury, including illness, disease, or impairment of a sexual or reproductive
organ, or mental anguish requiring psychiatric care, or sexual intercourse or sexual contact with a person known by
the perpetrator to be unconscious or mentally ill or mentally deficient. 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 the defendant has the
purpose to have sexual contact or sexual intercourse with the person while the person is incapable of giving consent.
A person can be imprisoned not more than ten years and/or fined not more than $10,000 for committing second degree sexual
assault.

Third degree sexual assault includes:
Having sexual intercourse with a person without that person’s consent.
The penalty for third degree sexual assault is imprisonment for not more than five years and/or a fine of not more than
$10,000.

Fourth degree sexual assault includes:
Having sexual contact with a person without that person’s consent. Sexual contact means any of the following:
Intentional touching, by the complainant or defendant, either directly or through clothing by the use of any body part
or object, of the complainant’s or defendant’s intimate parts if that intentional touching is either for the purpose of
sexually degrading or humiliating the complainant, or sexually arousing or gratifying the defendant.
The penalty for fourth degree sexual assault is imprisonment for not more than nine months in the county jail and/or a fine of
not more than $10,000.

Degree unknown
Assault was reported to:
UWW Police Services:
□
□
Yes □ No □
Local Law Enforcement:
Victim has been informed of support services and of their rights:
Please visit www.uww.edu/sasa for more information.
□
Dean of Students Office:
□
□
Victim wishes to speak with a counselor:
Yes
No
Please call Counseling Services (262) 472-1305 for more information or to schedule an appointment.
□
law enforcement investigation/criminal action □
Victim wishes to initiate or has already initiated:
no official action
university investigation/disciplinary action
□
----------------------------------------------------------------------------------------------------------------------------- --------------------------------Person completing form:
Date:
Submit this completed report to the Dean of Students Office within 24 hours.
Hyer Hall room 200
mackinm@uww.edu