FOR Report IT on Angela Shelton Day
Please fill out a separate form for each OFFENDER, not for each OFFENSE. You may fill out this form even if you have reported the offense to the police. It doesn’t matter when or where you were hurt. You can file in your own state, or you can travel to another state. You may also fill out this form for someone else as a representative if the victim is unable to fill it out. Do not fill out the form more than once for an offender.
Most sexual violence goes unreported.Report IT on Angela Shelton Day!
(All of your information is kept private and used for survey purposes only. You may be contacted for this campaign only if you choose to be. Your email will not be added to any list and we will not sell our email lists. Your information is kept private. Thank you for taking this survey.)

Who is filling this out?

Are you filing your own report with the police now?
Did you file a report with the police when the violence happened?
YES
If you reported it with the police, please comment on the process/outcome and how you were treated
Did you tell friends, family or others?
YES
If yes, how long after the offense(s) did you tell?
NAME OF VICTIM
First Name
(click "Anonymous" if you do not want to use your real name)
Last Name
CONTACT DETAILS
(must be a working email to protect against fraud)
You will be emailed a copy of your report to bring with you to the Report IT Day if you so chose
E-mail
City
Phone
State where crime occurred
If other, Name of the place
Age at the time of crime
(type in one age or multiple ages if more than one incident)
Gender
NATURE OF CRIME COMMITTED
Our lawmakers have created much confusion around sexual violence in this country. In 50 states there are many different words to describe child rape. Below are three options defined underneath as Rape, Unwanted Sexual Contact, and Other. Please read each before making your choice. If all of them occurred, chose each that applies per offense. Please fill out a new form for each offender.
Nature of crime committed √ No. of times the crime happened Date of offense (mm-dd-yy)
(If it happened during a period specify the period such as "FROM 1995-1998")
Rape
(which we will define as sexual contact with penetration of or by any body part ? (oral/anal/vaginal/penile/digital/object))

Unwanted sexual contact
(which we will define as contact without penetration with or by any sexual body part, - e.g., hand to breast, hand on penis. this means contact with the victim's sexual parts or having the victim make contact with the offender's sexual parts - and includes the use of objects to facilitate contact)

Others Specify

OFFENDER DETAILS
Did you know your offender?
If yes, what was your relationship with the offender?
Where did the abuse/violence take place?
Was alcohol involved in your case?
How many friends/family did you tell about the assault?
How did they react?
If Other please describe
 
            
Thank you for breaking your silence! One person can change the world.
 
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