CSA Crime Report Form

Section A: Introduction

This law applies to certain crimes reported to the police and other University officials known as Campus Security Authorities (CSA). CSA’s are federally mandated crime reporters. As such, CSA’s shall report, on a timely basis, any Act qualifying crimes that they are made aware of to the Northwestern University Police Department. University Police will use the submitted information to verify the appropriate classification of the crime. It is important for CSAs to document sufficient incident detail to allow University Police to properly classify the crime type. Visit Campus Security Authorities for additional information on CSA functions and responsibilities. An * indicates a required field.

Submission – To send the completed report form electronically, please click on the submit button at bottom of this form. You may also print this form and either fax (847-491-4931) or campus mail to Northwestern University Police (1201 Davis Street, Evanston, Attention David Schultz).

Section B: Dates
Please use calendar to select date.
Please use calendar to select date.
Please use calendar to select date.
Please use calendar to select date.
Section C: Crime Occurrence Location

Please provide building name, address, street name with cross streets or close address, or nearby buildings if it occurred outside. Consult the Act reportable locations as necessary.

On-Campus
On-Campus Residence Hall or Fraternity / Sorority
Non-Campus (University leased or controlled off-campus property)
Public Property (within or immediately adjacent to On-Campus property)
Off-Campus
Section D: Reported Crime

Check the box that best indicates the crime you are reporting. As needed, please refer to reportable crimes for crime definitions.

Murder
Manslaughter
Robbery
Burglary
Motor Vehicle Theft
Aggravated Assault
Sex Offense (Rape or Fondling)
Sex Offense: Non-forcible (Incest or Statutory Rape)
Arson
Dating Violence
Domestic Violence
Stalking

The following crimes need only be reported if the victim(s) of the reported crime was/were targeted specifically because of bias/prejudice against the victim.

Simple Assault
Larceny
Intimidation
Vandalism
Any other crime involving Bodily Injury

Please provide a brief description of the reported crime (what happened?) to help us classify it.

Section E: Hate Crime Reporting

Was the crime reported in Section D motivated by bias (was the victim specifically targeted because of prejudice i.e. a Hate Crime)?

Section E – 1:

What was the related bias type?

Race
Gender
Religion
Sexual Orientation
Ethnicity
Disability
National Origin
Gender Identity

Describe specific "Hate" action or speech which supports the "Hate Crime" classification.

Section F: Referrals

Certain student and employee violations referred to Student Affairs, Human Resources, etc. must be reported. These reportable law violations include:

Liquor Law Violation
Number of persons referred for Liquor.
Drug Law Violation
Number of persons referred for Drug(s).
Weapon Law Violation
Number of persons referred for Weapon(s).

If a liquor, drug, or weapon law violation referral is reported, the corresponding number of persons referred must be entered. Refer to the Clery Act Reportable Arrests and Referrals to view reportable crime definitions.

Section G: Secondary Reporting

Law Enforcement agency(s) the incident has also been reported to:

None
Northwestern University Police Department
Evanston Police Department
Chicago Police Department
Police Department report case number (if known)
Section H: Contact Information

Please provide a contact phone number  – or –  e-mail address.*

Format: XXX-XXX-XXXX
Section I: General Information

Crime Reporting – It is the policy of Northwestern University to ensure that the victims and witness to crimes are aware of their right to report criminal acts to the Northwestern University Police Department (847-491-3456). CSA’s should ask reporting party if they would like to report the crime to University Police. If the reporting party wants University Police contacted, the CSA should contact University Police and if the CSA can verify that University Police responded and took a police report, then it is not necessary for the CSA to complete and submit this form. However, if the CSA can’t verify that University Police responded and took a police report, then the CSA must complete and submit this form.

Anonymity – If a crime reporting party request anonymity, this request must be honored to the extent permitted by law. Accordingly, no information should be included on this form that would personally identify the victim without his/her consent.

Sexual incidents – CSA’s reporting a victim (student) reported incidence of sexual violence or harassment are encouraged to print and provide the reporting student with the CARE Resource Information Sheet.

CSA's reporting a victim (employee) reported incidence of sexual violence or harassment are encouraged to print and provide the reporting employee with the Employee Resource Information Sheet.

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