Clery Statistic Record Reporting Form

This form is to report statistics to be included in the University’s Annual Security Report, including Vice President of Student Services, Campus Police, Title IX Coordinator, Student Conduct and/or Housing & Residence Life. Information included in this form will be used only for the purpose of ensuring accurate calculation of Clery Crime Statistics for the Annual Security Report.

Clery Incident Recording Form

For individuals to whom Clery Crimes are reported to track information for the Clery Compliance Coordinator to compile for Annual Security Report.

Name of Staff Reporting Clery Categorized Incident*
First Last
Email of Staff Reporting Clery Categorized Incident*
Date which incident was reported:*
MM slash DD slash YYYY
Office where incident was reported:*
Clery Category or Categories
Hate Crime Category
Additional Crime Categories for Hate Crimes Only
VAWA Category
Clery Geographic Location*
- On-Campus
- On-Campus in Student Housing
- Non-campus building or property
- Public Property
- Separate Campus
- Off-Campus Trips (sponsored by the University)
Name of Responding Party/Accused Student*
First Last
Date of Incident*
MM slash DD slash YYYY
Specific Location of Incident*
Additional Notes or Details

Clery Incident Recording Form

Police, Health, and Safety

POLICE, HEALTH & SAFETY

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