CSA Reporting Form

CSA Reporting Form

CSA Reporting form

IF this incident requires an immediate Public Safety response, (for example crime in progress/emergency situation) dial 911 or 256-4911.

This form is to be used by identified Campus Security Authorities-CSAs who are required under the Federal Clery Act to report information they receive about crimes. The information collected from these forms will be used to compile required reporting statistics to be included in the University’s Annual Security Report and Daily Crime Log as required by law.

No information should be included on this form that would personally identify the student or other individuals involved in the incident. If you have questions about this form, please contact Public Safety, Clery Compliance Office at 856-256-4562.

Detailed information is necessary to properly log, categorize and report the crime.

Please complete all questions with as much information as you know, enter unknown if not known. All fields must be answered. DO NOT COPY and PASTE information from WORD or other word processing software into this form.  ALL INFORMATION MUST BE TYPED.

  1. Campus Security Authority-CSA Information
    4. Yes
  2. When did the incident occur?
  3. Description of Incident
  4. Please select the category that best fits the description of the incident you are reporting (if multiple places please check all that apply): *
    1. Murder/Non-Negligent Manslaughter – The willful (non-negligent) killing of one human being by another
    2. Manslaughter by Negligence – The killing of another person through gross negligence.
    3. Aggravated assault – An unlawful attack upon another for the purpose of inflicting severe or aggravated bodily injury. This type of assault is usually accompanied by the use of a weapon or means likely to produce death or serious bodily harm.
    4. Sexual Assault (Sex Offenses) – Any sexual act directed against another person, without the consent of the victim, including instances where victim is incapable of giving consent. (Rape, Fondling, Statutory Rape and Incest). Please indicate category:
      1. Rape
      2. Fondling
      3. Statutory Rape
      4. Incest
    5. Burglary – Unlawful entry into a structure to commit a felony or theft
    6. Robbery – Taking or attempting to take something by force, violence, threat, or by putting victim in fear
    7. Motor vehicle theft – theft of automobiles, trucks, etc., including joyriding (taking by person without lawful access)
    8. Arson – willful or malicious burning or attempt to burn structure, vehicle, or personal property of another
    9. Liquor, drug, and weapon law violations
      1. Liquor
      2. Drug
      3. Weapon
    10. Dating Violence – Violence committed by a person, who is or has been in a social relationship of a romantic or intimate nature with the victim
    11. Stalking – Engaging in a course of conduct directed at a specific person that would cause a reasonable person to fear for the person’s safety, or would cause substantial emotional distress.
    12. Other (provide details below)
  5. Who REPORTED the incident? *
    1. Victim
    2. Third Party
    3. Offender
  6. WHERE did the incident occur? *
    1. On Campus:
      1. in Residence Hall
      2. NOT in aResidence Hall
      Off Campus
      1. Public property immediately adjacent to campus (such as roadways, sidewalks, streets adjacent to campus)
      2. NOT affiliated with and NOT adjacent to campus
      Unknown
      1. Unknown
  7. Hate or Bias?
    1. Is there evidence that this incident was motivated by hate or bias? *
      1. Yes
      2. No
      Identify the potential category of prejudice (check all that apply)
      1. Race
      2. Gender
      3. Gender Identity
      4. Religion
      5. Sexual Orientation
      6. Ethnicity
      7. National Origin
      8. Disability
      9. Not Applicable
  8. Was the incident reported to police/public safety or another source at the University?
      1. Yes
      2. No
      3. Unknown