Public Safety Department

CSA Incident Report Form

Campus Security Authorities (CSA) are federally mandated crime reporters. CSAs shall report, on a timely basis, any Clery Act crimes that they are made aware of to the SCSU Public Safety Department. Public Safety 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 Public Safety 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.
(REMOVE? You may also print this form and either fax (320-308-3906) or campus mail to St. Cloud Public Safety Department (720 4th Ave. South, St. Cloud, MN 56301, Attention Clery Compliance Officer).)

Section 1: Incident Demographic Information

(only required for medical incidents)

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)

Section 2: Type of Crime

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

Injury
Hospitalization
Death

Yes
No

Yes
No

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

Section 5: Description of the Crime or Medical Emergency

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:

Section 8: Your Demographic Information

Contact Information:

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