Campus Security Authority Reporting Form
* All required fields are marked with an asterisk.
Date of report *
Name of campus security authority *
Email of campus security authority *
Date that incident occurred
If multiple incidents were reported or if the date of the incident is unknown, please add note
Last four digits of victim's UTDID number *
Reported by *
Reporting person's name *
Reporting person's phone number
Reporting person's Email address
If a third party reported the crime to you, please enter the relationship of the third party to the victim
If, to your knowledge, a law enforcement agency was notified, please enter the name of that agency.
Does the victim want the incident
investigated by law enforcement? *
Yes
No
Does the victim want the incident
investigated by the Dean of Students? *
Yes
No
Time of incident (if known)
Incident description (Please provide specific, detailed information) *
Incident Categories (check all that apply) * |
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Homicide |
Burglary |
If the crime was not listed above, please enter the additional crime category: |
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I am not sure how to classify this incident. |
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Is there any evidence that this crime was motivated by bias? *
Yes
No
If yes, please choose all categories of prejudice that apply: |
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Race |
Ethnicity |
Disability |
Gender Identity |
If you answered "yes" to the Motivated by Bias question, please provide a brief summary of
the evidence supporting a bias motivation:
Did this incident occur on campus or off campus? *
On Campus
Off Campus
Specific Location on Campus (if applicable)
