Campus Security Authority Reporting Form

Name of campus security authority Name of campus security authority First Last
Date that incident occurred Date that incident occurred / MM / DD YYYY
If multiple incidents were reported or if the date the incident occurred is unknown, please note below:
Reporting Person Contact Information
Reported by:

Reported by: the victim a third party
Name Name First Last
Phone Phone - ### - ### ####
Email
If a third party reported the crime to you, please enter the relationship of the third party to the victim:
Agency Notified
If, to your knowledge, a law enforcement agency was notified, please enter the name of that agency:
Does the victim want the incident reported to law enforcement?

Does the victim want the incident reported to law enforcement? Yes No
Incident Information
Location of incident (If known, provide exact address such as street name, building/residence hall name, office/room number, city, and state): *
Time of incident (if known) Time of incident (if known) : HH MM AM/PM
Incident description (Please provide specific, detailed information; can attach additional document if necessary.)
Upload a file (optional)

Attach Files
Incident Category
Click here for crime definitions.

Incident Category
Click here for crime definitions. Murder/Nonnegligent Manslaughter Negligent Manslaughter Rape Statutory Rape Incest Fondling Dating Violence Stalking Domestic Violence Burglary Robbery Aggravated Assault Arson Motor Vehicle Theft Hate Crime (Above crimes in addition to larceny, simple assault, vandalism and intimidation) Click for additional information. Liquor Law Violation Drug Law Violation Weapons Law Violation Other Crime Category I am not sure how to classify this incident.
Please provide as much information as possible so that University Police can make this determination.
If the crime was not listed above, please enter the additional crime category:
Is there any evidence that this crime was motivated by hate (bias)?

Is there any evidence that this crime was motivated by hate (bias)? Yes No
If yes, please choose any/all categories of prejudice that apply.

If yes, please choose any/all categories of prejudice that apply. Race Ethnicity Disability Gender Identity Gender Religion National Origin Sexual Orientation
If you answered “yes” to the Motivated by Bias question, please provide a brief summary of the evidence supporting a bias motivation:
What best describes the location of the crime? (If the crime occurred in multiple places, check all that apply.)

What best describes the location of the crime? (If the crime occurred in multiple places, check all that apply.) On-campus, residence hall On-campus, not in a residence hall Public property immediately adjacent to campus Non-campus in a University owned leased or controlled space (off-campus classroom, University sponsored trip) Unknown location, other I do not know which category this location would fall under.

Campus Security Authority Reporting Form

Campus Security Authority Reporting Form

Reporting Person Contact Information

Agency Notified

Incident Information