Incident Reporting Data Form - Susquehanna University printable pdf download

INCIDENT REPORTING DATA FORM

The form is solely for the purpose of collecting data for statistical reporting required by the Crime Awareness and

Campus Safety Act, as amended by the Higher Education Amendments of 1998.

A. Name and title of person completing form: (This form is to be completed by college officials with significant

responsibility for student and campus activities.)

__________________________________________________________________________

Department/Office_________________________________________Phone________________________________

Signature_________________________________________________Date_________________________________

B. Name and title of person to whom incident was reported:

_____________________________________________________________________________________________

C. Date and time incident occurred:

_________________________________________________________________________

D. Date and time incident was reported:

_____________________________________________________________________

E. Location of incident: (Name of building, if applicable, street address and room number. NOTE: room/apartment

number may be omitted when the incident reported is of a sensitive nature, and providing this information would

jeopardize confidentiality.)

_____________________________________________________________________________________________

F. Description of incident: (Do not require include information that may reveal identities of involved parties.)

_____________________________________________________________________________________________

G. Please answer the following questions about the incident:

Was alcohol involved?

__________________________________________________________________________________

Was a drug involved? (If so, specify type)

__________________________________________________________________

Was a weapon involved? (If so, specify type)

________________________________________________________________ Is there evidence that the offense

was motivated by bias? (If so, please explain in detail the type and nature of the bias)

_____________________________________________________________________________________________

H. Offender Demographics

Race ______________ Age (range)________________ Height/Weight _____________

Affiliations _________________________________ (e.g., faculty, staff, student, visitor, alumni, unknown, etc.)

Scar/tattoos _________________________________ Other Identifiers___________________________________

I. Resolution of incident/action taken: (If any)

_____________________________________________________________________________________________

Has this incident been reported to any law enforcement official? If Yes, to whom and when?

_____________________________________________________________________________________________

Has this incident been reported to any other University official? If Yes, to whom and when?

____________________________________________________________________________________________

Victim/survivor information

_____________________________________________________________________________

ADDITIONAL COMMENTS: (use reverse side if extra space is needed)

_____________________________________________________________________________________________

PLEASE RETURN IN SEALED ENVELOP MARKED CONFIDENTIAL TO:

Thomas A. Rambo

Assistant Vice President for Student Life &

Director of Public Safety

Susquehanna University

Incident Reporting Data Form - Susquehanna University

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