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Campus Security Authority (CSA) Incident Report Form

To assist Westminster College in complying with the federally mandated Clery Act, this form should be utilized by Campus Security Authorities (CSAs) to report crimes to the Director of Public Safety as soon as possible after a crime has been reported to the CSA to assess whether a Timely Warning or Emergency Notification needs to be issued. Under the Clery Act, a crime is reported to a CSA when a student, employee, or third party brings information about an alleged crime to the attention of the CSA, and the CSA believes the report was made in good faith. A CSA should also report any crime a CSA actually witnesses. The Clery Officer will use the information provided in this form to classify the crime for purposes of inclusion in the College’s annual crime statistics. Names and personal identifiers are not used in the Clery Crime Log Book or in the Annual Security Report.

Please complete this form to the best of your knowledge and abilities.

For any question or statement below that you do not have the facts, please simply state: UNKNOWN.

Remember the training. You: listen, refer, and report. You do not investigate.

Please give the Clery Bill of Rights Printable Resource below to the person who reported to you.

 Clery Bill of Rights Printable Resource


CSA Contact Information


Date Incident Occured

  Please choose at least one.



Note: When in doubt if an incident occurred on a Clery defined property, CSAs should still submit this completed form. A determination will be made by the Clery Officer as to whether the location is on Clery defined property.


A Hate Crime is a criminal offense committed against a person or property which is motivated in whole or in part, by the offender’s bias. Bias is a performed negative opinion or attitude toward a group of persons based on their race, gender, religion, gender identity, disability, sexual orientation, national origin or ethnicity.


Note: The initials are for tracking purposes and to avoid double counting incidents. This information will not be published in Safety Notices or Crime Statistics.

 Incident Labeling:

To the best of your knowledge what crimes were attempted or committed during this incident? Select all that apply.

Primary Crime Classification:

(If a crime below is motivated by bias noted by selecting yes above, it is also a hate crime.)

VAWA / Interpersonal Violence Classification:

Lesser Included Hate Crime Classification:

Arrests and Refferrals for Law Violations Classification:


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