Sexual Assault Supplemental Report Form
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8Sexual Assault Supplemental Report Form
•
It is recommended that the Sexual Assault Supplemental Report be used in the reporting, recording and
investigation of all sexual assault incidents, for each and every incident reported
•
Supervisory review of all sexual assault cases is encouraged
•
This form is not intended for use when the victim is a minor
Agency
ORI
Incident #
Case #
Name of Person Who Contacted Police (optional on information reports)
Method Report Received
911 Call
Non-emergency number
Online
Other (describe)
Address of Person Who Contacted Police
City
State
Zip Code
Telephone: Home
Work
Cell
Email
Relationship to Victim
Others Present with Victim During Interview
Location of Interview
Hospital
On Scene
At Department
Other (describe)
Dates
Date of Report (mm/dd/yyyy)
Time of Report
Date(s) of Incident (mm/dd/yyyy)
Time of Incident
From
To
Victim
Victim’s identifying or contact information may be exempt from disclosure under the Freedom of Information Act
and Crime Victim’s Rights Act or if this is a blind report.
Last Name
First Name
Middle Name
Any Aliases
Primary Language
Special Needs, Disability, Requests, etc.
Race/Ethnicity
Sex
Date of Birth (mm/dd/yyyy)
Height
Weight
M
F
Address
City
State
Zip Code
Telephone: Home
Work
Cell
Email
Emergency Contact
Emergency Contact Telephone
Best Way to Safely Contact Victim
Victim Demeanor Observed at Time of Interview (select all that apply) Include detailed description in narrative
Other (describe)
Afraid/Fearful
Confused
Shaking/Trembling
Angry
Flat Affect
Tearful/Crying
Calm/Controlled
Nervous/Agitated
Withdrawn/Quiet/Flat Affect
Are there any injuries?
Y
N
Does the victim report pain?
Y
N
If yes, detail in narrative
Follow up needed
If yes, describe
Were weapons used to hurt/injure/threaten?
Y
N
Does the victim believe she/he may have been drugged?
Y
N
If yes, detail in narrative
Follow up needed
If yes or unsure, detail in narrative
Unsure
Did the victim voluntarily consume alcohol
Y
N
Did the victim voluntarily take other controlled
Y
N
within 24 hours of incident?
Follow up needed
substance within 96 hours of incident?
Follow up needed
If yes, detail in narrative
If yes, detail in narrative
Has sexual abuse by suspect been ongoing?
Y
N
Any other known or possible victims?
Y
N
If yes, how long?
Follow up needed
If yes, list names and contact information
Follow up needed
Victim Assistance Checklist
Victim’s Personal Safety Concerns Addressed
Sexual Assault Victim Rights and Services Information Provided
Victim Given Department Contact Information
Crime Victim’s Rights and Compensation Information Provided
International Association of Chiefs of Police
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