Clery Incident Report - California
CALIFORNIA STATE UNIVERSITY, LONG BEACH CAMPUS SECURITY AUTHORITY
CLERY INCIDENT REPORT
One important purpose of the Clery Act is to encourage the accurate collection of campus crime statistics in order to promote and enhance campus crime awareness
and campus safety through reliable statistical crime reporting. The purpose of this report form is to provide Campus Security Authorities (CSAs) with a uniform
mechanism for documenting the (who, what, when, where) of crimes reported to them, especially, confidential reporting.
Clery provides the following definitions for reporting locations.
1)
On-campus property: Any building or property owned or controlled by the University within the same reasonably contiguous geographic area and used
by the University in direct support of, or in a manner related to, the University's educational purpose, including any buildings or property that is owned by
the University but controlled by another person and which is frequently used by students and supports institutional purposes such as a food or other retail
vendor. (Excluding Residential Colleges)
2)
On-campus Residential Colleges. (Hillside and Parkside Colleges)
3)
Non-campus property: Any building owned or controlled by a student organization that is officially recognized by the University; or any building or
property owned or controlled by the University that is used in direct support of, or in relation to the University’s educational purposes, is frequently used by
students, and is not within the same reasonably contiguous geographic area of the University (includes Beachside/Blair Field/Greeks/Foundation, etc.).
4)
Public property: All public property, including: thoroughfares, streets, sidewalks, parking facilities, that is within the campus, or immediately adjacent to
and accessible from campus.
5)
Off campus: Locations not included above.
Data collected on this form shall not include personal identifying information. The student status of the offender or victim is not a relevant fact when determining if a
report should be accepted. All reports involving any of the listed crimes must be documented and reported to the University Police Department. The annual
Clery statistical count shall be determined by the University Police Department. Use a separate report form for every Clery reportable incident; if in doubt
…
file a report.
A Campus Security Authority (CSA) is defined in the Annual Clery Report and on the reverse side of this form.
Homicide
Aggravated Assault
Burglary (excluding auto burglary)
Domestic violence
Manslaughter
Sex Offense (Rape)
Motor Vehicle Theft
Dating violence
Robbery
Sexual Battery (Fondling)
Arson
Stalking
Hate Crime (In conjunction with above and/or below listed incidents):
Bodily injury
Vandalism
Intimidation
Theft
E-messaging
Telephone
Other
Include category
Gender Identity
Disability
of Bias:
Race
Ethnicity/national origin
Gender
Sexual Orientation
Religion
Location of Incident:
On-campus (excluding student housing)
On-campus (student housing)
Off campus
Public property (adjacent to campus)
Unknown location
Non-campus property (
Beachside
/Blair/Greeks)
Date of Incident: Time of Incident: CSA Tracking #:
Name of CSA receiving report: CSULB Department/Unit:
Date report received: Time report received:
CSA received report from:
Victim
Witness
Friend
Offender
Family
Other
Police Report filed?
Yes
No
Unk.
Date/time reported to
Police Department:
CSULB PD Case#: (If known)
Other PD & #
Sex Offense: Sex offenses are of special concern to the campus community because historically they have been under reported. The victim of a sex
offense typically desires confidentiality and anonymity; as a result he/she will often seek a reporting source other than law enforcement such as a designated
Campus Security Authority. Because the sex offender may continue to pose a threat to the community, the threat potential needs to be quickly evaluated
and the campus community alerted/warned as deemed necessary. In this regard, the following additional information is requested.
Sex Offense:
Victim: (
student
faculty
staff
other )
Known offender: (
friend
classmate
acquaintance
date other)
Unknown offender: (stranger)
Victim was NOT physically injured (excluding emotional/psychological trauma)
Victim was physically injured
Describe injuries: ________________________________________________
Sex Offense:
Alcohol involved:
Offender
Victim
Drugs/narcotics involved:
Offender
Victim
Weapon involved:
Yes
No
Describe weapon:
Description of Offender:
Race: Gender: _ Age:
Height:___ Wt: Hair Color: ___
Eye Color:
Physical Characteristics:
Brief Description of Crime:
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