CAMPUS SECURITY AUTHORITY CRIME & INCIDENT REPORT

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If you are an individual identified as a “Campus Security Authority,” use this form to report the required information about specified crimes (listed below) pursuant to the federal Clery Act. The information collected from these forms is used to prepare a compilation of statistical crime information for inclusion in TCC’s Annual Security Report.

Reports of offenses that pose an immediate or continuing serious threat to the campus community that may require an emergency notification or timely warning to the community are to be reported immediately to campus security officials and/or to the Director of Safety and Security. Submission of this report form should follow that immediate report.

Campus Security Authority Information:

Is this a test Submission?(Required)

Yes

Name

First

Last

Phone

Campus

Department

Date of this report

MM slash DD slash YYYY

When & how did you receive this information?

Date reported to you

MM slash DD slash YYYY

Incident Information

Date of incident

MM slash DD slash YYYY

Time of incident

Hours

Minutes

AM/PM

If this is a continuing event, please describe date and time range

Is This a Criminal Offense?

Criminal Homicide: Murder, non-negligent manslaughter, the willful (non-negligent) killing of one human being by another or negligent manslaughter, the killing of another person through gross negligence (do not include traffic fatalities)

Sex Offense (forcible): forcible rape, forcible sodomy, sexual assault with an object, sexual fondling

Sex Offense (non-forcible): Statutory rape (victim under the legal age of consent) or incest

Robbery: Taking or attempting to take something by force, threat of force or violence

Aggravated Assault: Attack of a person that inflicts severe or aggravated bodily injury often with the use of a weapon or by means likely to produce death or great bodily harm

Burglary: Unlawful entry into a structure to commit a felony or theft (thefts from open areas are not burglaries)

Motor Vehicle Theft: theft of any self-propelled vehicle that runs on land surfaces

Arson: Willful or malicious burning / attempt to burn a dwelling house, public building, motor vehicle, aircraft or personal property of another

Other

Select the category that best describes the incident you are reporting

Is this a Hate Crime?

Any criminal offense committed against a person or property that is bias motivated. Is there evidence that the incident was motivated by bias against any of the characteristics below?

Hate Crime Characteristics

Race

Gender

Gender Identity

Religion

Disability

Sexual Orientation

Ethnicity

National Origin

if you selected "yes" to the previous question, please select which characteristics the bias was motivated by

VAWA Offences

Does the incident you are reporting meet any of the following criteria?

Were the victim and offender known to each other?

Does this incident qualify as Dating Violence?

Dating violence is defined as: an act committed by a person who has been in a social relationship of a romantic or intimate nature with the victim and where the existence of such a relationship shall be determined by based on a consideration of the following factors: length of the relationship, type of relationship, frequency of interactions between the persons involved in the relationship.

Does this incident qualify as domestic violence?

Domestic Violence includes felony or misdemeanor crimes of violence committed by a current or former spouse or intimate partner of the victim, by a person
with whom the victim shares a child in common, by a person who is cohabitating with or has cohabitated with the victim as a spouse or intimate partner, by a person similarly situated to a spouse of the victim under the domestic or family violence laws of the jurisdiction receiving grant monies, or by any other person against an adult or youth victim who is protected from that person's acts under the domestic or family violence laws of the jurisdiction.

Does this incident qualify as stalking?

Stalking means engaging in a course of conduct directed at a specific person that would cause a reasonable person to fear for his or her safety or the safety of others, or suffer substantial emotional distress.

Incidents Involving Arrests or Judicial Referrals

Incidents involving arrests or judicial referrals

Liquor law violation

Drug law violation

Weapon law violation

Action Taken

Arrest

Referral

Victim Information

It is the policy of TCC to ensure that victims of and witnesses to crime are aware of their right to report criminal acts to the police and to report college policy violations to the appropriate office (i.e. student conduct violations to the Campus Dean of Student Services, employee conduct violations to the Office of Human Resources). However, if a reporting person requests anonymity, this request must be honored to the extent permitted by law. Accordingly no information should be included on this form that would personally identify the victim without his/her consent.

Gender

Age

Please enter a number from 0 to 150.

Victim is a:

Provide Name and Contact Information of victim if he/she gives permission:

First Name

Last Name

Phone

Address

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Is the victim willing to provide his/her name for security/police follow-up?

Has the victim made a TCC Security Report?

Has the victim made a police report?

To which police agency?

Has a Student Conduct Code/Disciplinary referral been made?

Has a referral to the Office of Human Resource been made?

Offender Information (provide known or reported information)

Gender

Age

Please enter a number from 0 to 150.

Offender is a:

Is the victim willing to provide offender's name for security/police follow-up?

Provide name and contact information of offender, if available

First Name

Last Name

Telephone

If you observed the incident and can identify the offender, the victim's permission is not required to provide the offender's identity and contact information

Who reported the incident to you?

If third party, relationship to victim:

Unless confidentiality has been requested, provide the Third Party's identity and contact information

First Name

Last Name

Telephone

Incident Details

Location

If known, provide the specific location (campus, building, room, street address, etc.)

Describe the incident in detail. This will be used to aid in determining the proper Clery classification, to clarify if it is an on-campus, non campus, or public area, and to aid in identifying duplicate reports.

If you categorized the incident as a hate crime, dating violence, domestic violence, or stalking, provide a brief description of the evidence supporting that categorization.

Type the characters from the image below

For questions regarding this form contact Mike Powell, Director of Public Safety at 757-822-1797 or email at mpowell@tcc.edu