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CSA-Clery Act Incident Report Form


If this is an emergency, dial 911.

One of the purposes of the Clery Act is to encourage accurate and timely reporting of campus crime statistics. This form provides campus security authorities (CSAs), other than University Police, with a uniform method to document reported Clery crimes. We will not use this information to identify the victim, but rather to meet Clery Act requirements and increase public safety. For Clery Act purposes, Texas State University affiliation of the involved parties is not a relevant fact as to whether this report form is to be completed. Directing and referring the reporting party to the University police does not satisfy the Clery Act. In order for the University to satisfy its critical Clery Act requirements, all CSA's must complete this form as soon as they learn of crimes. In addition, CSAs must respond to an annual request sent by the Clery Act Compliance Coordinator to gather crime data or your status on whether you fulfilled your responsibility of reporting crimes throughout the calendar year.

Background Information

 
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If off-campus was selected, please type specific location name and address.

Involved Parties

1. If a victim does not want police intervention, please DO NOT provide their name or personally identifiable information. Instead, enter "Requested Confidentiality" and select the "Victim/Survivor" option under "Individual's Role."

2. If you do not know the name of the victim or subject, then enter "Unknown." Please make sure to enter both a victim and subject entry even if names not known.

3. Please list all individuals involved, completing as many of the listed fields as you can provide. Please note that all individuals involved, whether they are affiliated with Texas State or not, should be listed below. 

Involved party 1

Clery Crime Description and Narrative

A CSA is NOT responsible for properly classifying and counting Clery reportable crimes, however, please refer to the Clery Crimes List and Clery Act Geography webpages for your convenience. 

This field is required.
This field is required.
Does the victim want police intervention and want to be contacted by law enforcement? (If yes, please offer assistance with notifying the police as it is required under 34 CFR 668.46(b)(11)).(Required)
This field is required.
Has the incident been reported to a law enforcement agency?(Required)
You must make at least one selection.
Was anyone arrested by law enforcement?(Required)
This field is required.
This field is required.
Did the victim request confidentiality? (If yes, please remove name above in "Involved Parties" section and enter "Requested Confidentiality"). If you are not sure, still provide the name and UPD will NOT reach out to the victim unless he/she states they want police involvement.(Required)
This field is required.
Who reported this to you?(Required)
This field is required.
This field is required.
What is the victim's campus affiliation?(Required)
You must make at least one selection.
What is the subject's campus affiliation?(Required)
You must make at least one selection.

Supporting Documentation

Photos, video, email, and other supporting documents may be attached below. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

Submission