This form should be completed by those individuals as "campus security
authorities" who are required to report information they receive about
specified crimes 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 campus' Annual Security
Report.
It is the policy of Simpson College to ensure that victims and witnesses to
crime are aware of their fight to report criminal acts to the police, and to
report College policy violations to the appropriate office (e.g., student
conduct violations to the Office of Security.) 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.
The Office of Security will use the form to determine the category of crime
and location under which the crime should be reported according to the
requirements of the Clery Act.
| Person Submitting Report |
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| Phone |
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| Report made by |
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| Please identify and indicate
relationship to victim |
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| Date Incident Occurred |
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| Time Incident occurred |
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Description of the
incident or crime
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Location of
Incident
Identify building name, address, etc. Be as specific as possible.
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Location where
incident occurred
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Sex Offenses
Examples of sex offenses are rape, sodomy, sexual assault with an object,
fondling, incest, and statutory rape.
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| Was this crime a sexual
offense? |
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| If yes, were the victim and the
assailant acquainted? |
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| If yes, was either the
victim or the assailant under the influence of alcohol or drugs? |
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Victim
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Assailant
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Hate Crimes
Hate crime information is required to be reported for each of the following
crimes (criminal homicide, sex offense, robbery, aggravated assault, burglary,
motor vehicle theft, and arson) and for any other crime involving bodily
injury.
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| Was this incident motivated by
hate or bias? |
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If yes, identify
the category of prejudice
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If yes, provide a brief explanation of the determination
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Alcohol, Drug and
Weapons Law Violations
Check all that apply |
If weapons, please
describe
|
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| Number of individuals arrested
or referred for campus disciplinary action |
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| |
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