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