Clery Report Form

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
Phone
Report made by Victim    Third Party
Please identify and indicate relationship to victim
Date Incident Occurred
Time Incident occurred
Description of the incident or crime

Location of Incident
Identify building name, address, etc. Be as specific as possible.

Location where incident occurred

On Campus, but not in student housing
On campus, student housing
Off campus affiliated property (owned, controlled, or affiliated with the campus, e.g. leased property, fraternity, student co-op)
Off campus public property immediately adjacent to campus
Off campus NOT affiliated with or not adjacent to campus
Unknown

Sex Offenses
Examples of sex offenses are rape, sodomy, sexual assault with an object, fondling, incest, and statutory rape.

Was this crime a sexual offense? Yes    No
If yes, were the victim and the assailant acquainted? Yes    No
If yes, was either the victim or the assailant under the influence of alcohol or drugs?
        Victim        Yes, alcohol    Yes, drugs    No
        Assailant   Yes, alcohol    Yes, drugs    No

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.

Was this incident motivated by hate or bias? Yes    No
If yes, identify the category of prejudice

Race         Ethnicity         National Origin
Religion     Disability         Sexual Orientation

If yes, provide a brief explanation of the determination


Alcohol, Drug and Weapons Law Violations
Check all that apply  Alcohol       Drugs       Weapons
If weapons, please describe


Number of individuals arrested or referred for campus disciplinary action