EmailMe Form - Campus Security Authority Incident Report Form

Campus Security Authority Incident Report Form

This form is to be completed whenever any faculty or staff person with significant responsibility for student activities becomes aware of a crime that has taken place. The awareness can come from a direct report from a student or staff member or from a third party. Even if the person making the report tells you that the crime has been reported to a police agency, it is important that this form be completed and forwarded to the Public Safety Department in a timely manner.

If this is a confidential report, please indicate whether you are a:
Professional Counselor
Medical Professional
Name of Campus Security Authority Completing Form *
First Last
Phone *
### - ### - ####
Campus Security Authority Email *
Date of Incident *
MM / DD / YYYY
Description of Incident *
Does the victim want to remain anonymous? *
If No, please provide name and contact information.
First Last
Contact Information
Type of Incident (Definitions of each incident below) *
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.

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.

Hate Crimes – the above listed crimes fall under hate crimes along with larceny, theft, simple assault, intimidation and destruction of property, when victim intentionally selected due to race, gender, sexual orientation, ethnicity, disability, national origin or gender identity.
If there is evidence that this crime was motivated by hate or bias, please identify the potential category or prejudice (check all that apply).
Race
Gender
Sexual Orientation
Ethnicity
Disability
National Origin
Gender Identity
If the crime was motivated by hate or bias, please provide a brief summary of evidence supporting a hate motivation.
Sex Offenses - forcible sexual act directed against another person, forcibly and/or against that person’s will; or not forcibly or against the person’s will where the victim is incapable of giving consent. *
Forcible Rape - the carnal knowledge of a person, forcibly and/or against the person’s will; or not forcibly or against the person’s will where the victim is incapable of giving consent because of his/her temporary or permanent mental or physical incapacity (or because of his/her youth).

Forcible Sodomy - oral or anal sexual intercourse with another person, forcibly and/or against that persons will; or not forcibly against the person’s will where the victim is incapable of giving consent because of his/her youth or because of his/her temporary or permanent mental or physical incapacity.

Sexual Assault with an Object - the use of an object or instrument to unlawfully penetrate, however slightly, the genital or anal opening of the body of another person, forcibly and/or against that person’s will; or not forcibly or against the persons will where the victim is incapable of giving consent because of his/her youth or because of his/her temporary or permanent mental or physical incapacity.

Forcible Fondling - the touching of the private body parts of another person for the purpose of sexual gratification, forcibly and/or against that person’s will; or, not forcibly or against the persons’ will where the victim is incapable of giving consent because of his/her youth or because of his/her temporary or permanent mental incapacity.
Sex Offenses - non-forcible unlawful, non-forcible sexual intercourse and Violence Against Women Act (VAWA). *
Incest - non-forcible sexual intercourse between persons who are related to each other within the degrees wherein marriage is prohibited by law.

Statutory Rape - non-forcible sexual intercourse with a person who is under the statutory age of consent.

VAWA - Violence Against Women Act
Domestic Violence - felony or misdemeanor crimes of violence committed by a current or former spouse of the victim, by a person with whom the victim shares a child in common, by a person who is cohabitating with or has cohabited with the victim, as a spouse, by a person similarly situated to a spouse of the victim under the domestic or family violence laws of the jurisdiction received grant monies, or by any other person against an adult or youth victim who is protected from that person’s acts under the domestic or family violence laws of the jurisdiction.

Dating Violence - committed by a person who is or has been in a social relationship of a romantic or intimate nature with the victim; and where the existence of such a relationship shall be determined based on a consideration of the following factors; the length of the relationship, the type of relationship; the frequency of interaction between the persons involved in the relationship.

Stalking - engaging in a course of conduct directed at a specific person that would cause a reasonable person to; fear for his or her safety or the safety of others; or suffer substantial emotional distress.
Please answer the following if the incident was a sex offense:

Was the crime committed forcibly and/or against the victim's will?
Yes
No
Unknown
Was the victim incapable of giving consent because of temporary or permanent mental or physical incapable of giving consent because of temporary or permanent mental or physical incapacity (or because the victim is below the age of consent)?
Yes
No
Unknown
Is there evidence that the assault was facilitated by administration of drugs or alcohol?
Yes
No
Unknown
If you checked "yes" to the previous questions, please explain:
Was the incident reported to you by the victim, the offender, or a third party? *
Location of incident: (If the incident occurred in multiple places, please check all that apply) *
On-Campus, residence halls
On-Campus, not in residence halls
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
If the specific location (building name, street address, etc.) is known, please provide it.
Has this been reported to Lock Haven University Title IX Coordinator?
Yes
No

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