Campus Security Authority Crime Report Form
According to federal law, specifically The Clery Act, previously known as The Student Right to Know and Campus Security Act of 1990, The SRTC Police Department is required to report “statistics concerning the occurrence of certain criminal offenses reported to the local police agency or any official of the institution who is defined as a 'Campus Security Authority.'"
The definition of “Campus Security Authority”, according the federal law, is as follows: “An official of an institution who has significant responsibility for student and campus activities, including, but not limited to, student housing, student discipline, and campus judicial proceedings."
This Federal Clery Act applies to certain crimes reported to the police and other College officials known as Campus Security Authorities. Campus Security Authorities are federally mandated crime reporters. As such, these authorities shall report, on a timely and informative basis, any qualifying crimes that they are made aware of to the SRTC Police Department. College Police will use the submitted information to verify the appropriate classification of the crime.
Crime Reporting Form for Campus Security Authorities
Section A: Submission
To send the completed report form electronically, please click on the submit button at bottom of this form. You may also print this form and email it to the SRTC Police Department at amcnair@southernregional.edu. If you have any questions contact SRTC Police at 229-726-9371.
Section B: Contact Information
First Name
*
Last Name
*
Department
Phone
*
E-Mail Address
*
Section C: Dates
Date Crime Reported to CSA: mm/dd/yyyy
Section D: Crime Occurrence Location
Please provide building name, address, street name with cross streets or close address, or nearby buildings if it occurred outside. Consult the Act Reportable Locations as necessary.
Location
*
Classification
On-Campus
Non-Campus (College leased or controlled off-campus property)
Public Property (within immediately adjacent to On-Campus property)
Off-Campus
Section E: Reported Crime
Check the box that best indicates the crime you are reporting. As needed, please refer to Reportable Crimes for crime definitions.
Murder
Manslaughter
Robbery
Burglary
Motor Vehicle Theft
Aggravated Assault
Sex Offense (Rape or Fondling)
Sex Offense: non-forcible (Incest or Statutory Rape)
Arson
Dating Violence
Domestic Violence
Stalking
Other Crime
The following crimes need only be reported if the victim(s) of the reported crime was/were targeted specifically because of bias/prejudice against the victim.
Simple Assault
Larceny
Intimidation
Vandalism
Any other crime involving Bodily Injury
Number of Crime Victims
Please provide a brief description of the reported crime (what happened?) to help us classify it.
Section F: Hate Crime Reporting
Was the crime reported in Sectin D motivated by bias (was the victim specifically targeted because of prejudice i.e. Hate Crime)?
Hate Crime
Yes
No
Section G: Referrals
Certain student and employee violations referred to Student Affairs, Human Resources, etc. must be reported. These reportable law violations include:
Violation
Liquor Law Violation
Drug Law Violation
Weapon Law Violation
If a liquor, drug, or weapon law violation referral is reported, the corresponding number of persons referred must be entered. Refer to the Clery Act Reportable Arrests and Referrals section to view reportable crime definitions.
Number of violators:
Section H: Secondary Reporting
Law Enforcement agency(s) the incident has also been reported to:
Case Number (if known)#