Crime Incident Report Form - Swosu

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Crime Incident Report Form
This form should be completed by those individuals identified as “campus security authorities”
who are required to report information they receive about specified crimes (described below)
pursuant to the federal Clery Act. The information collected from these forms will be used to
prepare a compilation of statistical crime information that will be included in the campus’ Annual
Security Report.
It is the policy of the SWOSU to ensure that victims and witnesses to crime are aware of their
right to report criminal acts to the police, and to report University policy violations to the
appropriate office (e.g., student conduct violations to the Office of Dean of Students). However,
if a reporting person requests anonymity, this request must be honored to the extent permitted by
law. Accordingly, no information should be included on this form that would personally identify
the victim without his/her consent.
SWOSU Campus Police will use this form to determine the category of crime and location under which the
crime should be reported according to the requirements of the Clery Act. Please forward this
completed form to:
SWOSU Campus Police Department via campus mail or fax (580) 774-7116
Person Receiving Report: ____________________________
Phone Number: ________________
Report Made by:
______Victim
______Third Party Please identify relationship to victim: _______________________________________
Date and Time the Incident occurred: ______________________________________________________
Description of the incident or crime: _______________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Location of Incident
Identify building name, address, etc.; be as specific as possible): _________________________________
____________________________________________________________________________________
Crime Incident Report Form
This form should be completed by those individuals identified as “campus security authorities”
who are required to report information they receive about specified crimes (described below)
pursuant to the federal Clery Act. The information collected from these forms will be used to
prepare a compilation of statistical crime information that will be included in the campus’ Annual
Security Report.
It is the policy of the SWOSU to ensure that victims and witnesses to crime are aware of their
right to report criminal acts to the police, and to report University policy violations to the
appropriate office (e.g., student conduct violations to the Office of Dean of Students). However,
if a reporting person requests anonymity, this request must be honored to the extent permitted by
law. Accordingly, no information should be included on this form that would personally identify
the victim without his/her consent.
SWOSU Campus Police will use this form to determine the category of crime and location under which the
crime should be reported according to the requirements of the Clery Act. Please forward this
completed form to:
SWOSU Campus Police Department via campus mail or fax (580) 774-7116
Person Receiving Report: ____________________________
Phone Number: ________________
Report Made by:
______Victim
______Third Party Please identify relationship to victim: _______________________________________
Date and Time the Incident occurred: ______________________________________________________
Description of the incident or crime: _______________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Location of Incident
Identify building name, address, etc.; be as specific as possible): _________________________________
____________________________________________________________________________________
The location where this incident occurred was:
______ On campus, but not in student housing
______ On campus student housing
______ Off-campus affiliated property (owned, controlled, or affiliated with the campus; e.g.,
leased property, fraternity, student co-op)
______ Off-campus public property immediately adjacent to campus
______ Off-campus, NOT affiliated with or not adjacent to campus
______ Unknown
Sex Offenses
Examples of sex offenses are rape, sodomy, sexual assault with an object, fondling, incest, and
statutory rape.
Was this crime a sexual offense ? ______ Yes ______ No
If yes, were the victim and the assailant acquainted? ______ Yes ______ No
If yes, were either the victim or the assailant under the influence of alcohol or drugs?
Victim:
______ No
Yes, alcohol ______
Yes, drugs _____
Assailant:
______ No
Yes, alcohol ______
Yes, drugs _____
Hate Crimes
Hate crime information is required to be reported for each of the following crimes (criminal
homicide, sex offense, robbery, aggravated assault, burglary, motor vehicle theft, and arson) and
for any other crime involving bodily injury.
Was this incident motivated by hate or bias? ______ Yes ; ______ No .
If yes, identify the category of prejudice:
______ Race
______ Ethnicity
______ National Origin
______ Religion
______ Disability
______ Sexual Orientation
If yes, provide a brief explanation of the determination:
_______________________________________
Alcohol, Drug and Weapons Law Violations
Check all that apply:
______ Alcohol
______ Drugs
______ Weapons Describe:
________________
Referred for campus disciplinary action? __________
Referred to campus police?
__________

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