Clery – CSA Crime Report Form

Campus Security Authority Crime/Incident Report Form
Time Incident Reported

Check the box that best indicate the crime you are reporting. As needed, refer to the crime definitions listed below.

The following crimes need only be reported if the victim(s) of the reported crime was/were targeted specifically of bias/prejudice against the victim
Hate Crime Bias Type
Does the victim wish to be contacted by Public Safety?
To the best of your knowledge, were any of the following offices or agencies notified of this incident? Please check all that apply


(Definitions from the Handbook for Campus Safety and Security Reporting)

Murder/Non-Negligent Manslaughter
The willful (non-negligent) killing of one human by another.

Negligent Manslaughter
The killing of another person through gross negligence.

The taking or attempting to take anything from value of 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
An unlawful attack by one person upon another for the purpose of inflicting severe or aggravated bodily injury. This type of assault usually is accompanied by the use of a weapon or by means likely to produce death or great bodily harm. It is not necessary that injury result from an aggravated assault when a gun, knife or other weapon is used that could or probably would result in a serious potential injury if the crime were successfully completed.

“Penetration, no matter how slight, of the vagina or anus with any body part or object, or oral penetration by a sex organ of another person, without the consent of the victim.”

“The touching of the private body parts of another person for the purpose of sexual gratification, without the consent of the victim, including instances where the victim is incapable of giving consent because of his/her age or because of his/her temporary or permanent mental incapacity.”

Sexual intercourse between persons who are related to each other within the degrees wherein marriage is prohibited by law.

Statutory Rape
Sexual intercourse with a person who is under the statutory age of consent.

Any 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.

The unlawful entry of a structure to commit a felony or a theft. For reporting purposes this definition includes: unlawful entry with intent to commit a larceny or a felony; breaking and entering with intent to commit a larceny; housebreaking; safecracking; and all attempts to commit any of the aforementioned.

Motor Vehicle Theft
The theft or attempted theft of a motor vehicle. Theft of any self-propelled vehicle that runs on land surface and not on rails, such as: sports utility vehicles, automobiles, trucks, buses, motorcycles, motor scooters, trail bikes, mopeds, all-terrain vehicles, self-propelled motor homes, snowmobiles, golf carts and motorized wheelchairs. (Classify as motor vehicle theft all cases where automobiles are taken by persons not having lawful access, even though the vehicles are later abandoned — including joy riding.)

Weapon Law Violations
The violation of laws or ordinances dealing with weapon offenses, regulatory in nature, such as: manufacture, sale or possession of deadly weapons; carrying deadly weapons, concealed or openly; furnishing deadly weapons to minors; aliens possessing deadly weapons; all attempts to commit any of the aforementioned.

Drug Abuse Violations
Violations of state and local laws relating to the unlawful possession, sale, use, growing, manufacturing, and making of narcotic drugs. The relevant substances include: opium or cocaine and their derivatives (morphine, heroin, codeine); marijuana; synthetic narcotics (Demerol, methadone); and dangerous non-narcotic drugs (barbiturates, Benzedrine).

Liquor Law Violations
The violation of laws or ordinance prohibiting the manufacture, sale, transporting, furnishing, possession of intoxicating liquor, maintaining unlawful drinking places; bootlegging; operating a still; furnishing liquor to minor or intemperate person; using a vehicle for illegal transportation of liquor; drinking on a train or public conveyance; all attempts to commit any of the aforementioned. (Drunkenness and driving under the influence are not included in this definition.)

Hate Crimes
A criminal offense committed against a person or property that is motivated, in whole or in part, by the offender’s bias. Hate-specific crimes may include any of the above defined crimes or also:


The unlawful taking, carrying, leading, or riding away of property from the possession or constructive possession of another.


To willfully or maliciously destroy, injure, disfigure, or deface any public or private property, real or personal, without the consent of the owner or person having custody or control by cutting, tearing, breaking, marking, painting, drawing, covering with filth, or any other such means as may be specified by local law.

To unlawfully place another person in reasonable fear of bodily harm through the use of threatening words and/or other conduct, but without displaying a weapon or subjecting the victim to actual physical attack.

Simple Assault
An unlawful physical attack by one person upon another where neither the offender displays a weapon nor the victim suffers obvious severe or aggravated bodily injury involving apparent broken bones, loss of teeth, possible internal injury, severe laceration or loss of consciousness.

Dating Violence
Violence committed by a person who is or has been a in a social relationship of a romantic or intimate nature with the victim.

Domestic Violence
Felony or misdemeanor crimes of violence committed by a current or former spouse of the victim, a person whom the victim shares a child in common, a person who is cohabitating with or has cohabitated with the victim as a spouse or someone similarly situated to spouse.

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.