Campus Security Authority Incident Report Form

Your Name Your Name * First Last
Your Phone Number Your Phone Number * - ### - ### ####
Your E-mail Address *
Did the reporter/victim ask to remain anonymous? *

Did the reporter/victim ask to remain anonymous? Yes No
What is the reporter/victim's name and contact information? *

If the reporter/victim requested to remain anonymous, we will maintain their anonymity, but we need to know their name to compare reports to ensure we are not double counting statistics.
When was this incident reported to you? When was this incident reported to you? * / MM / DD YYYY
When did this incident occur? *

Please be as specific as you can. If the incident occurred several times, please give a date range. (Ex: 1/12/23 OR during the Spring semester, OR ten times over the last year)
Has this incident been reported to anyone or any agency in addition to the report you are making now? *

Has this incident been reported to anyone or any agency in addition to the report you are making now? Yes No I'm Not Sure

For example, a local police department, UTA's Title IX Office, your supervisor, etc.
If yes, who made the report, when did they make the report, and to whom was the report made? *

Please be as specific as you can.
Location of Incident *

Location of Incident On Campus (Residence Hall or apartment) On Campus (Other than Residence Hall) Non-Campus Property (owned, controlled, or affiliated with campus; e.g., leased property, fraternity or sorority, university sponsored hotel stay) Public Property immediately adjacent to campus (sidewalk, street, sidewalk which are adjacent to campus) Off Campus, Not affiliated or adjacent to campus (e.g., City of Arlington) Unknown If you know the address or name of the building, please enter that information below:
What type of Clery Crime was the incident? *

What type of Clery Crime was the incident? Murder or Non-Negligent Manslaughter Negligent Manslaughter Forcible Sex Offense Non-Forcible Sex Offense Aggravated Assault (resulting in severe injury, possibly due to the use of a weapon) Simple Assault (pushing, shoving, pulling, slapping, etc.) Dating or Domestic Violence Stalking Robbery Burglary Motor Vehicle Theft Arson Intimidation Destruction/Damage/Vandalism of Property Unsure

Please select at least one option, but you may select more than one option.
Was the incident motivated by the victim's belonging to a protected class? If so, on what basis was the crime committed? *

Was the incident motivated by the victim's belonging to a protected class? If so, on what basis was the crime committed? Race Gender Gender Identity Sexual Orientation Religion The incident does not seem to be a hate motivated crime.
Please provide an explanation of the report made to you. *

Please provide as many details as possible.
Please upload any documents you think may be helpful.

Attach Files

Sometimes a reporter/victim will e-mail an explanation to someone. Please upload the e-mail from the reporter.