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Campus Security Authority Reporting Form
Date of Report
Date the incident occurred
Name of campus security authority
Department and contact number
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
The Offender
A Third Party
First Name
Last Name
Phone
Email
If a third party (e.g.
roommate, friend, parent
) 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 address, office number:
(see location details, below)
Time of incident (
if known
)
Incident description
(Please provide specific, detailed information.)
Incident Category
Criminal Homicide
Robbery
Aggravated Assault
Hate Crime
Dating Violence
Arrest for Liquor Law Violation
Arrest for Drug Law Violation
Arrest for Weapons Law Violation
Burglary
Motor Vehicle Theft
Arson
Domestic Violence
Stalking
Referral for Liquor Law Violation
Referral for Drug Law Violation
Referral for Weapons Law Violation
I am not sure how to classify this incident.
Is there any evidence that this crime was motivated by bias?
Yes
No
If yes, please choose any/all categories of bias 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:
Location Details
What best describes the location of the crime?
(If the crime occurred in multiple places, check all that apply.)
On-Campus Student Housing Facility (i.e. residence hall, fraternity, sorority, St. James complex, Main St. Commons)
On-Campus, not in a student housing facility (i.e. academic and/or administrative building, university grounds)
Public Property (i.e. streets and sidewalks immediately adjacent to campus)
Noncampus in a University owned, leased, or controlled space (off-campus classroom, athletic practice/game facility, university-sponsored trip)
Unknown location, other
I do not know which category this location would fall under
