Bacone College Campus Security Authority Incident Report Form

This form is to be used by identified campus security authorities 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 statistics to be included in the campus Annual Security Report.

No information should be included on this form that would personally identify the student or other individuals involved in the incident.

Please complete as much information as you know, University Police will use the information submitted to determine the appropriate category for the incident in the Annual Security Report.

1. Campus Security Authority name:

2. Phone number (xxx) xxx-xxxx

3. Date of incident (if known) MM/DD/YYYY

4. Description of the incident, please provide as much information regarding the incident as you know. Do not identify the victim or other individuals involved in the incident.

5. Please select the category that best fits the the description of the incident you are reporting.

Homicide - Murder, non-negligent manslaughter, and negligent manslaughter (including vehicular manslaughter)

Aggravated assault - unlawful attack upon another with intent to inflict severe injury or great bodily harm

Sex offense - Rape, sodomy, sexual fondling, sexual assault with object, statutory rape and incest

Burglary - unlawful entry into a structure to commit a felony or theft

Robbery - taking/attempting to take something by force, violence, threat, or by putting victim in fear

Motor vehicle theft - theft of automobiles, trucks, etc., including “joyriding” (taking by person without lawful access)

Arson - willful or malicious burning/attempt to burn structure, vehicle, or personal property of another

Liquor, drug, and weapon law violations - underage possession/consumption; distribution to minors; use, possession, or distribution of controlled substances; possession or use of an illegal weapon

6. Was the incident reported to you by the victim, the offender, or a third party?

Victim

Third Party

Offenders

7. What best describes the location of the incident, if the incident occurred in multiple places please check all that apply.

On-campus, residence hall

On-campus, not in a residence hall

Off-campus, public property immediately adjacent to campus (sidewalks, streets adjacent to campus)

Off-campus, NOT affiliated with and NOT adjacent to campus

At an unknown location

8. If the specific location (building name, street address, etc.) of the incident is known please provide it.

9. Is there evidence that this incident was motivated by hate or bias?

Yes

No

10. If you checked "No" for Question #9, please hit "Submit" at the bottom of the page. If you checked "Yes" to Question #9, please answer Questions #10 and 11. Identify the potential category of prejudice (check all that apply):

Race

National Origin

Religion

Sexual Orientation

Ethnicity

Disability

Gender

11. Please provide a brief summary of evidence supporting a hate motivation: