CSA Incident Report Form

Section 1: Incident Demographic Information

Date Incident Reported to CSA:

Date Crime Occurred:

Name of Victim: (only required for medical incidents)

Location:

Location Classification: On-Campus
On-Campus in a Residence Hall
Non-Campus (University leased or controlled off-campus property, education abroad, fraternity or sorority house, University-sponsored off campus event, etc.)
Public Property (within or immediately adjacent to on-campus property)

City:

State/Province:

Country:

Section 2: Type of Crime

Clery-Reportable Crimes: 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
Other Crime:

Section 3: Medical Emergencies

Medical Incident: Injury
Hospitalization
Death

Admitted to hospital? Yes
No

Did hospitalization occur as a result of program participation? Yes
No

Was the hospitalization during program activities or free time? Activities
Free Time

Section 4: Hate Crimes

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

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

Yes
No

Number of Victims:

Section 5: Description of the Crime or Medical Emergency

Provide a brief description of the reported incident (what happened?) to help us classify it:

Section 6: Liquor, Drug and Weapons Violations

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

Liquor Law Violation
Drug Law Violation
Weapon Law Violation

Section 7: Law Enforcement Involvement

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

None
St. Cloud Police Department
Other:

Case Number:

Section 8: Your Demographic Information

Contact Information:

First Name:

Last Name:

Department:

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

Phone:

E-Mail: