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CSA Crime Report Form

This Report Form is only to be used by designated Campus Security Authorities (CSAs) to report Clery Act incidents. All others should contact University Police directly.

Submission of this report will not open a police investigation. The information will be used to determine whether there is a serious and ongoing threat to the Northwestern community and to classify, count and report Clery crimes. The incident will be included in the daily crime log without any personally identifying information.

* Required Field

Section A: Introduction

Campus Security Authorities (CSA) are required by Federal law to report, on a timely basis, any Clery Act crimes that they are made aware of to the Northwestern 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.

Submission – To send the completed report form electronically, please click on the submit button at bottom of this form.

Section B: Dates

Crime Occurrence

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. See the Clery Act Geography section pdf.


(check this box if unsure whether incident occurred at a Clery reportable location)

Section D: Reported Crime

Check the box that best indicates the crime you are reporting. As needed, see Sections 1 and 3 in Clery Information pdf. *


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.

Do the victim(s) and respondent(s) know one another?

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)?

Hate Crime*

Section E – 1:

What was the related bias type?

Bias Type*

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:


If a liquor, drug, or weapon law violation referral is reported, the corresponding number of persons referred must be entered. Refer to Section 2 in Clery Information pdf.

Section G: Secondary Reporting

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

Police Department report case number (if known)

Section H: Reporting CSA 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 witnesses to crimes are aware of their right to report criminal acts to the Northwestern Police Department (847-491-3456). CSAs should ask the 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 cannot 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 requests 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 – CSAs reporting a student or employee reported incident of sexual misconduct should also complete the Sexual Misconduct Report Form.

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