CSA Crime Report Form


Introduction

As part of the federal Jeanne Clery Disclosure of Campus Security Policy and Campus Crime Statistics Act (20 USC § 1092(f)), otherwise known as the Clery Act, Act qualifying incidents reported to University Police, from various sources, including Campus Security Authorities (CSA), are required to be annually published in an Annual Security Report and made available to the campus community. One purpose of the Clery Act is to encourage the reporting and collection of accurate campus crime statistics to promote crime awareness and enhance campus safety. The information collected from these forms will be used to compile statistics to be included in the Annual Security Reports that Northwestern University publishes and distributes each fall.

On a timely basis, CSA's are obligated to report Clery Act qualifying crimes however, are encouraged to report all crimes reported to them to University Police. CSA's should only report those crimes that have not been previously reported to University Police or another University CSA. To review information on reportable Clery Act crimes, reportable disciplinary referrals and/or the Clery Act incident occurrence locations that are reportable, please refer to the Clery Act Definitions / Campus Security Authority (CSA)Reporting sheet (PDF). For additional information on the Clery Act and CSA responsibilities, visit the Campus Security Authority web page or contact the Clery Act Coordinator at 847-491-3752.

Campus Security Authority Incident Report Form

Do not provide name / contact information if the person reporting the incident requests confidentiality.

The CSA is to document as much of the requested information on the Form, excluding identity if confidentiality is requested, as s/he knows. University Police will use the submitted information to verify the appropriate classification of the crime.

PLEASE FILL OUT ALL RELEVANT FIELDS.
A) Date Incident Reported to CSA: MM/DD/YYYY

B) CSA contact information (*entry of contact information is mandatory)
First Name*:
Last Name*:
Phone*: XXX-XXX-XXXX
E-mail:

C) Date(s) of incident occurrence (SELECT ONE)
Specific Date: MM/DD/YYYY, or
Date Range: From to , or
Date(s) Unknown:

D) Incident description: Provide specific information related to the reported incident.

E) Select the category that best fits the description of the crime you are reporting:
Homicide – Murder, non-negligent manslaughter, and negligent manslaughter (including vehicular manslaughter)
Aggravated assault - unlawful attack upon another with intent to inflict severe injury or great bodily harm
Sex offense, forcible - Rape, sodomy, sexual fondling, or sexual assault with object

Were the victim and offender acquainted?
Yes     No     Unknown
Sex offense, non forcible - statutory rape (victim under the legal age of consent) or incest
Burglary - unlawful entry into a structure to commit a felony or theft
Robbery – taking / attempting to take something by force, violence, threat, or by putting victim in fear
Motor vehicle theft - theft of automobiles, trucks, etc., including "joyriding" (taking by person without lawful access)
Arson - willful or malicious burning/attempt to burn structure, vehicle, or personal property of another
Liquor (A), Drug (B), and/or Weapon Law (C) Violation (note below if incident involved an arrest (any individual) or if violation resulted in a student referral instead of an arrest) - (A) underage possession or consumption, distribution to minors - (B) use, possession or distribution of controlled substances or possession of drug paraphernalia -(C) possession or use of an illegal weapon.

Liquor Law Violation
Arrest or, Student Referral

Drug Law Violation
Arrest or, Student Referral

Weapon Law Violation
Arrest or, Student Referral
Other crime (Note crime type below)

F) Was the crime reported to you by the victim or a third party?

* Skip entry of reporting party name and phone number if confidentiality requested.
Victim     Third Party*

*If Third Party, please identify relationship to victim

Reporting Party First Name:
Reporting Party Last Name:
Phone: XXX-XXX-XXXX

G) What best describes the location of the crime? If the crime occurred in multiple places, check all that apply.
On-campus, residence hall, fraternity or sorority
On-campus, not in a residence hall
Off-campus, public property immediately adjacent to campus (sidewalks, streets, etc)
Off-campus in University leased or controlled space
Off-campus, NOT affiliated with and NOT adjacent to campus
Unknown location

H) If known, provide specific occurrence location (building name, street address, office number, etc.).
Per the Clery Act, the criminal offense (excluding "other") listed in section E, theft, simple assault, intimidation, vandalism and any other crime involving bodily injury are reportable as a hate crime if a listed crime was motivated by the offender's bias. For information on Hate Crime definitions visit http://www.northwestern.edu/up/forms/forms.html and select the "CSA Crime Report Form Definitions" link.

Is there evidence that this crime was motivated by bias?
Yes     No
If you answered "No" to the above question: click "Submit Form" at the bottom of the page.

If you answered "Yes" to the above question: complete the following sections.

Identify the potential category of prejudice (check all that apply):
Race
National Origin
Religion
Sexual Orientation
Ethnicity
Disability

Provide a brief summary of the evidence supporting a bias motivation: