Campus Security Authority Crime Report Form

University of California, Santa Cruz
Campus Security Authority Crime Report Form

Campus Police will use the information submitted to determine the appropriate category for the crime in the Annual Security Report.You may submit this form electronically by selecting the submit button at the bottom of this page or you may print it out and forward the completed form to Sgt. Mike Kimura, UCPD,mtkimura@ucsc.edu, 831-459-2231 or by fax to 831-458-5021.

Campus Security Authority name:

Phone number:

E-mail:

Position:

Crime reported to you by:

Victim
Third party.

Please identify relationship to victim:

Date and Time the Incident Occurred:

Month:	Day:	Year:
Time:

Description of facts [please describe any incident that could be classified as criminal homicide, sex offense [see below], robbery, aggravated assault, burglary, motor vehicle theft, or arson. The Campus Police will make final crime classification decisions based upon the information provided]:

Location of Incident
Identify building name, street address, etc.; be as specific as possible:

This incident occurred:
On-campus, but not in student housing
On-campus student housing
Off-campus affiliated property
(owned, controlled, or affiliated with campus;
e.g., leased property, UTC, UCSC INN, fraternity, student co-op)
Off-campus public property immediately adjacent to campus
Off-campus, NOT affiliated with and NOT adjacent to campus
At an unknown location

Sex Offense [E.g. rape, sodomy, sexual assault with object, fondling, incest, statutory rape.]

As described, does the incident involve a sex offense?	Yes No
Was the crime committed forcibly and/or against the victim's will?	Yes No
Or was the victim incapable of giving consent because of temporary or permanent mental or physical incapacity (or because victim is below age of consent)?	Yes No
	VICTIM	ACCUSED
Is there evidence that the assault was facilitated by administration of drugs?	Yes No	Yes No
Is there evidence that the assault was facilitated by administration of alcohol?	Yes No	Yes No

If yes, please explain.

Hate Crimes [Hate crime information must be reported for criminal homicide, sex offenses, robbery, aggravated assault, burglary, motor vehicle theft, arson, and any other crime involving bodily injury.]

Is there evidence that this incident was motivated by hate or bias?	Yes No
If yes, identify the potential category of prejudice(check all that apply):	Race Ethnicity National Origin	Religion Disability Sexual Orientation

If yes, provide a brief summary of evidence supporting a hate motivation:

Alcohol, Drug and Weapons Law Violations [Check all that apply]:

Alcohol Drugs Weapons Describe:

Number of individuals arrested or referred for campus disciplinary action for each offense:

Alcohol:
Drugs:
Weapons:
Describe:

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