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Campus Life / Safety & Campus Police / C.S.A. Incident Report Form

Campus Security Authority (C.S.A.) Incident Report Form

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Incident Contact Information

Do not provide name/contact information if the person reporting the incident requests confidentiality.

Name

Phone Number

Incident Details

Date or Dates the Incident Occurred

Check here if the date the incident occurred is unknown

Date unknown

Incident Description

Incident Category

Select all that apply

Homicide - Murder

Non-negligent manslaughter; and negligent manslaughter (including vehicular manslaughter)

Aggravated Assault

Unlawful attack upon another with intent to inflict sever injury or great bodily harm

Sex Offense

Rape

Incest

Statutory Rape

Fondling

Burglary

Unlawful entry into a structure to commit a felony or theft

Robbery

Taking or 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 Violation

Underage possession or consumption; distribution to minors

If liquor violation, did incident involve an arrest (any individual) or a student disciplinary referral?

Arrest

Disciplinary Referral

Drug Violation

Use, possession, or distribution of controlled substances or possession of drug paraphernalia

If drug violation, did incident involve an arrest (any individual) or a student disciplinary referral?

Arrest

Disciplinary Referral

Weapon Law Violation

Possession or use of an illegal weapon

If weapon law violation, did incident involve an arrest (any individual) or a student disciplinary referral?

Arrest

Disciplinary Referral

Dating Violence

Violence committed by a person who is or has been in a social relationship of a romantic or intimate nature with the victim

Domestic Violence

Felony or misdemeanor crimes of violence committed by a current or former spouse or intimate partner of the victim

Stalking

Engaging in a course of conduct directed at a specific person that would cause a reasonable person to fear for his/her safety or the safety of others

Other Crime Category

Agency Notified

If, to your knowledge, a law enforcement agency was notified, please enter the name of that agency

Reported by

Was the crime reported to you by the victim, a third party, or both?

Third Party

Victim

Both

If a third party reported the crime to you, please enter the relationship of the third party to the victim

Reporting Party Name (Do not enter if confidentiality is requested)

Reporting Party Phone Number (Do not enter if confidentiality is requested)

Incident Location

What best describes the location of the crime? If the crime occurred in multiple places, check all that apply

On campus, residence hall

On campus, not in a residence hall

Public property immediately adjacent to campus (sidewalks, streets, etc.)

Off Campus in University owned leased or controlled space

Unknown location or other

Incident Address

Motivated by Bias

Is there evidence that this crime was motivated by bias?

Yes

If you answered Yes to the Motivated by Bias question, please choose any/all potential categories of prejudice

Race

National Origin

Disability

Gender

Religion

Ethnicity

Sexual Orientation

Gender Identity

If you answered Yes to the Motivated by Bias question, please provide a brief summary of the evidence supporting a bias motivation

940 Second Street Portsmouth Ohio 45662

Main: (740) 351-3205

Admission: (740) 351-4778

TTY: (740) 351-3159

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