Clery Act Incident Report Form

    Please complete the following information:

    Name and contact information for the person submitting the report:

    Title (please choose):

    First Name:

    Last Name:

    Email:

    Telephone:

    Name of student involved in the incident:

    First Name:

    Last Name:

    Date and time of the incident:

    Date:

    Time (local):

    Location where the incident took place:

    Address:

    City/ZIP:

    Country:

    Was a police report filed?
    YesNo

    If yes, please indicate the date and time when the police report was filed:

    Details regarding the crime or incident:



    Definitions of reportable incidents

    U.S. Department of Education – The Handbook for Campus Safety and Security Reporting