Clery CSA Reporting Form Clery Campus Security Authority (CSA) Reporting Form Date Incident Reported to CSA CSA Name Phone Number Email* Confirm Email* Date of occurance (as close as possible) Time of incident Location of incident (building or address) Type of location (where incident occurred) On campus Off campus public property immediately adjacent to campus (sidewalks, street, etc.) Off campus property belonging to a campus-affiliated organization (ex. fraternity house) Off campus not affiliated with or adjacent to campus Off campus educational program (conference, study abroad, study at remote location) Unknown location Incident description — specific information related to the reported incident Has this been reported to Title IX Yes No Category which best fits the description of the crime you are reporting (if unsure describe in detail above) Murder non-negligent manslaughter and negligent manslaughter Robbery Aggravated assault Burglary Motor vehicle theft Liquor law violation Liquor law violation - Arrested Liquor law violation - Referred for student conduct Drug law violation Drug law violation - Arrested Drug law violation - Referred for student conduct Weapons law violation Weapons law violation - Arrested Weapons law violation - Referred for student conduct Forcible sex offense Forcible sex offense - Forcible rape Forcible sex offense - Forcible sodomy Forcible sex offense - Sexual assault with an object Forcible sex offense - Forcible fondling Non-forcible sex offense Non-forcible sex offense - Incest Non-forcible sex offense - Statutory rape Domestic violence Dating violence Stalking Was the incident reported to law enforcement Truman State University Police Kirksville Police Department Local Police Department (list agency name below) If you selected Local Police Department in the question above, please list the name of the agency Was the incident reported to University Judicial Officer (Student Conduct) Title IX Compliance Officer Dean of Students Residence Life Does there appear to be evidence this incident was motivated by the perpetrator's bias Yes No If you answered "Yes" to the question above, describe the indication of bias Please identify the bias Race (actual or perceived) Sexual orientation Gender Gender identity Religion National origin Ethnicity Disability Do not fill in the following field Google Recaptcha response