Campus Security Authority Report Form

CSA Reporter & Incident Background Information

Full Name of CSA Reporter

Phone Number of CSA Reporter

Email Address of CSA Reporter

UM-Flint Affiliation of CSA

Date of incident

Time of incident

Location of Incident

Specific location

Did the incident occur on property owned, controlled, or leased by the College or College-affiliated organization?

Did the incident occur at a College-sponsored activity or event?

Involved Parties

Please list all individuals/organizations involved, including as many of the listed fields as you can provide. However, DO NOT list yourself (reporter).

Please use the following information to determine the roles of involved parties:

Survivor/Victim - Person that has suffered harm as a result of a crime/incident.

Witness - Person that saw or heard crime/incident take place and/or may have relevant information.

Accused/Suspect - Person that is allegedly responsible for the crime/incident.

Other - Any person that does not fit into the other provided roles.

If parties wish to remain anonymous, this form may be completed without the inclusion of personally identifiable information.

Incident Information

This section collects information on the Clery crime disclosure as provided to the CSA (reporter). Please provide as much of the following information as possible. The inclusion of personally identifiable information of involved parties is not required.

Incident Description

Incident/Crime Category

Was the crime, as reported, motivated by bias?(Required)

If bias-motivated, select all categories of bias that apply.

Does the survivor/victim wish to have the incident reported to law enforcement?(Required)

Was this incident reported to a law enforcement agency and/or any other University office? If yes, please list the name of the law enforcement agency and/or University office notified. **If no or unsure, please type "N/A".(Required)

The University makes many resources available to survivors/victims and witnesses of crime at no cost. Would any of these parties like resources emailed to them? If so, please list their role(s) and email address(es) below

If the survivor/victim of sexual violence would like to be contacted by the Confidential CAU affiliated Sexual Assault Advocate, please provide their contact information below

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.

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Campus Security Authority Report Form

CSA Reporter & Incident Background Information

Involved Parties

Incident Information

Supporting Documentation