Campus Security Authority Crime Report Form

This form should be completed by those individuals identified as a “Campus Security Authority” (CSA) who are required to report information they receive about specified crimes (see Definitions) pursuant to the federal Clery Act. The information collected from these forms will be used to prepare a compilation of statistical crime information that will be included in the annual Campus Safety Report: A Shared Responsibility pamphlet.

It is the policy of Purdue University Calumet to ensure that victims and witnesses to crime are aware of their right to report criminal acts to the police, and to report university policy violations to the appropriate office (e.g., student conduct violations to the Dean of Students). If a reporting person requests anonymity, this request will be honored to the extent possible. This form may also be used to record and report any crime (not just a Clery Act specific crime) which is reported to the Campus Security Authority. University Police will use this form to determine the category of crime under which the crime should be reported according to the requirements of the Clery Act.

Reporting Information

Report made by and to:

*(if agrees to provide)

Identify third party relationship to victim and (if agrees to provide)…

* Was crime also reported to University Police? OR

* Other Law Enforcement agency?

Crime Occurrence Description:


Sex Offense

* Was reported crime a sexual offense?

If yes, were the victim and offender acquainted?

If yes, was the victim or offender under the influence of alcohol or drugs?

* Victim?

If yes, identify which

* Offender?

If yes, identify which

Hate Crime

* Was reported crime motivated by hate or bias?

Hate Crime Bias Type

Alcohol, Drug and Weapon Law Violations

(check all that apply – as needed, refer to Definitions sheet)


* Referred for campus disciplinary action?