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Campus Security Authority Reporting Form

 
 
Date of Report  *
Name of Campus Security Authority  *
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
  The Victim         Third Party
First Name  *
Last Name  *
Phone Number  *
Email Address  *
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.
Agency
Does the victim want the incident reported to law enforcement ?
  Yes         No
 
 
 
- Incident Information -
 
 
Location of incident (building name, street add, office num)
Time of incident (if known)
Incident description (Please provide specific, detailed information)
 
 
 
- Incident Category -
 
 
Please see below for definitions of offenses
  Homicide
  Burglary
  Aggravated Assault
  Robbery
  Sex Offense (Forcible)
  Sex Offense (Non-Forcible)
  Motor Vehicle Theft
  Arson
  Dating Violence
  Domestic Violence
  Stalking
  Hate Crime
  Arrest for Liquor Law Violation
  Referral for Liquor Law Violation
  Arrest for Drug Law Violation
  Referral for Drug Law Violation
  Arrest for Weapons Law Violation
  Referral for Weapons Law Violation
  I am not sure how to classify this incident
Please provide as much information as possible so that campus personnel can make this determination
Other Crime Category
If the crime was not listed above, please enter the additional crime category
Is there any evidence that this crime was motivated by bias ?
  Yes         No
If yes, please choose any/all categories of prejudice that apply
  Race
  Gender
  Ethnicity
  Religion
  Disability
  National Origin
  Gender Identity
  Sexual Orientation
If you answered yes to the Motivated by Bias question, please provide a brief summary of the evidence supporting a bias motivation
 
 
 
- Location -
 
 
What best describes the location of the crime ? (If the crime occurred in multiple places, check all that apply. Please see below for further explanation as to the geography)
  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 (fraternity, sorority, off-campus classroom)
  Unknown location, other
  I do not know which category this location would fall under
 
 
 
- Crime Definitions -
 
 
Homicide

Murder/non-negligent manslaughter: the willful (non-negligent) killing of one human being by another

Negligent Manslaughter: the killing of another person through gross negligence

Sex Offenses Forcible

Forcible rape: carnal knowledge of a person forcibly and/or against the person’s will; or not forcibly or against the person’s will where the victim is incapable of giving consent because of his/her temporary or permanent mental or physical incapacity (or because of his/her youth)

Forcible sodomy: oral or anal sexual intercourse with another person, forcibly and/or against that person’s will; or not forcibly and/or against that person’s will where the victim is incapable of giving consent because of his/her youth or because of his/her temporary or permanent mental or physical incapacity

Sexual assault with an object: use of an object or instrument to unlawfully penetrate, however slightly, the genital or anal opening of the body of another person, forcibly and/or against that person’s will; or not forcibly or against the person’s will where the victim is incapable of giving consent because of his/her youth or because of his/her temporary or permanent mental or physical incapacity

Forcible fondling: touching of the private body parts of another person for the purpose of sexual gratification, forcibly and/or against that person’s will or, not forcibly or against the person’s will where the victim is incapable of giving consent because of his/her youth or because of his/her mental incapacity

Sex Offenses Non-Forcible

Incest: non-forcible sexual intercourse between persons who are related to each other within the degrees wherein marriage is prohibited by law

Statutory Rape: non-forcible sexual intercourse with a person who is under the age of consent

Robbery

Taking or attempting to take anything of value from the care, custody, or control of a person or persons by force or threat of force or violence and/or by putting the victim in fear

Aggravated Assault

Unlawful attack by one person upon another for the purpose of inflicting severe or aggravated bodily injury

Burglary

Unlawful entry of a structure to commit a felony or a theft

Motor Vehicle Theft

The theft or attempted theft of a motor vehicle

Arson

Willful or malicious burning or attempt to burn with or without intent to defraud a dwelling house, public building, motor vehicle or aircraft, personal property of another, etc.

Dating Violence

Violence committed by a person who is or has been in a social relationship of a romantic or intimate nature with the victim; and where the existence of such a relationship shall be determined based on a consideration of the following factors:

    • the length of the relationship
    • the type of the relationship
    • the frequency of interaction between the persons involved in the relationship
Domestic Violence

Felony or misdemeanor crimes of violence committed by a current or former spouse or intimate partner of the victim, by a person with whom the victim shares a child in common, by a person who is cohabitating with or has cohabitated with the victim as a spouse or intimate partner, by a person similarly situated to a spouse of the victim under the domestic or family violence laws of the jurisdiction…or by any other person against an adult or youth victim who is protected from that person’s acts under the domestic or family violence laws of the jurisdiction

Stalking

Engaging in a course of conduct directed at a specific person that would cause a reasonable person to fear for his or her safety or the safety of others, or suffer substantial emotional distress

Liquor Law Violation

The violation of state or local laws or ordinances prohibiting the manufacture, sale, purchase, transportation, possession, or use of alcoholic beverages

Drug Law Violation

The violation of laws prohibiting the production, distribution and/or use of certain controlled substances and the equipment or devices utilized in their preparation and/or use

Illegal Weapons Possession

The violation of laws or ordinances prohibiting the manufacture, sale, purchase, transportation, possession, concealment, or use of firearms, cutting instruments, explosives, incendiary devices, or other deadly weapons

 
 
 
- Geography Definitions -
 
 
On Campus

Any building or property owned or controlled by an institution within the same reasonably contiguous geographic area and used by the institution in direct support of, or in a manner related to, the institution’s educational purposes, including residence halls; and

Any building or property that is within or reasonably contiguous to the area identified in paragraph (1) of this definition, that is owned by the institution but controlled by another person, is frequently used by students, and supports institutional purposes (such as food or other retail vendors)

Non-Campus Building or Property

Any building or property owned or controlled by a student organization that is officially recognized by the institution; or

Any building or property owned or controlled by an institution that is used in direct support of, or in relation to, the institution’s educational purposes, is frequently used by students, and is not within the same reasonably contiguous geographic area of the institution

Public Property

All public property, including thoroughfares, streets, sidewalks, and parking facilities, that is within the campus, or immediately adjacent to and accessible from the campus

 
 
 
- Form Security Validation -
 
 
Please click the checkbox below to complete user verification.
 
 
 
- Review and Submit -
 
 
Please review the information within the form to insure content accuracy and completeness then, click submit.
 
Form 0011