INDIANA STATE UNIVERSITY CRIMEINCIDENT REPORT FORM (IN COMPLIANCE WITH

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Indiana State University Crime/Incident Report Form

Indiana State University Crime/Incident Report Form

(In compliance with the Jeanne Clery Disclosure of Campus Security Policy and Campus Crime Statistics Act)

Campus Security Authority (CSA) Information:

Date Reported to CSA:______________________ Time Reported to CSA:____________________

Name of Reporting CSA:_____________________ Department:_____________________________

Title:_____________________________________ Contact Number:_________________________

Crime/Incident Information:

Date of Crime/Incident:______________________ Time of Crime/Incident:_____________________

Location Where Crime/Incident Occurred:

_____On Campus Building or Property _____Residence Hall

_____Non-Campus Building or Property _____Public Property

Address or Description of Location:________________________________________________________

Type of Crime/Incident Being Reported:

We are required to report the following crimes/incidents:

Murder, Manslaughter, Forcible Sex Offense, Non-Forcible Sex Offense, Robbery, Aggravated Assault, Burglary, Motor Vehicle Theft and Arson. If you believe that the crime/incident that you are reporting falls into one of the preceding categories, then please describe the crime/incident below.

____________________________________________________________________________________

For Student Judicial Use Only:

_____Alcohol Violation Disciplinary Referral

_____Drug Violation Disciplinary Referral

_____Weapons Violation Disciplinary Referral

For Public Safety Use Only:

_________Clery Act Offense Type

_________Crime/Incident Not Reportable

Bias/“Hate” Crime Information:

1. Was this crime perpetrated based upon the victim’s race, gender, religion, sexual orientation, ethnicity or disability? YES NO

If you answered “YES,” then please specify:________________________________________________

2. Was the victim physically assaulted/battered? YES NO

Does the victim wish to be contacted by the Public Safety Department? YES NO

If you answered “YES,” then please fill out the additional information about the victim:

Name:____________________________________ Telephone Number:_________________

If you need assistance completing the form contact Tammy Hurst at 812-237-7829 and return to the Department of Public Safety.

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