Campus Security Authority Incident Report Form

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Please indicate if you are a *

Professional Counselor

Medical Professional

Religious Counselor

None of the Above

Is this a confidential report

Yes

Name of Campus Security Authority Completing Form

First Name

Last Name

Phone Number *

Campus Security Authority Email *

Incident Details

Date Incident was Reported to You *

Year

Month

Day

Date of Incident

Year

Month

Day

If not all information is available, leave the missing item blank

Description of Incident

Does the victim want to remain anonymous

Yes

If No, please provide victim’s name and contact information.

Victim's First Name

Victim's Last Name

Victim's Contact Info

Type of Incident (Definitions of each incident below)

Incident Type Definitions

Homicide - Murder, non-negligent manslaughter, and negligent manslaughter (including vehicular manslaughter).
Aggravated assault - unlawful attack upon another with intent to inflict severe injury or great bodily harm.
Burglary - unlawful entry into a structure to commit a felony or theft.
Robbery – taking/attempting to take something by force, violence, threat, or by putting victim in fear.
Motor vehicle theft - theft of automobiles, trucks, etc, including “joyriding” (taking by person without lawful access).
Arson - willful or malicious burning/attempt to burn structure, vehicle, or personal property of another.
Liquor, drug, and weapon law violations – underage possession/consumption; distribution to minors; use, possession, or distribution of controlled substances; possession or use of an illegal weapon.

Hate Crimes – the above listed crimes fall under hate crimes along with larceny, theft, simple assault, intimidation and destruction of property, when the victim is intentionally selected due to race, gender, sexual orientation, ethnicity, disability, national origin or gender identity.

Hate Crimes

Is there anything to suggest that the victim(s) of the above-listed crimes were selected because of their race, gender, sexual orientation, ethnicity, disability, national origin or gender identity? Check all that apply.

If there is evidence that the crime was motivated by hate or bias, please provide a brief summary of evidence supporting a hate motivation.

Sex Offense

Sex Offenses are forcible sexual acts directed against another person, forcibly and/or against that person’s will; or not forcibly; or against the person’s will where the victim is incapable of giving consent. See additional definitions below.

Sex Offense Definitions

Forcible Rape - the carnal knowledge of a person, forcibly and/or against the person’s will; or not forcibly or against the person’s will where the victim is incapable of giving consent because of his/her temporary or permanent mental or physical incapacity (or because of his/her youth).
Forcible Sodomy - oral or anal sexual intercourse with another person, forcibly and/or against that persons will; or not forcibly against the person’s will where the victim is incapable of giving consent because of his/her youth or because of his/her temporary or permanent mental or physical incapacity.
Sexual Assault with an Object - the use of an object or instrument to unlawfully penetrate, however slightly, the genital or anal opening of the body of another person, forcibly and/or against that person’s will; or not forcibly or against the persons will where the victim is incapable of giving consent because of his/her youth or because of his/her temporary or permanent mental or physical incapacity.
Forcible Fondling - the touching of the private body parts of another person for the purpose of sexual gratification, forcibly and/or against that person’s will; or, not forcibly or against the persons’ will where the victim is incapable of giving consent because of his/her youth or because of his/her temporary or permanent mental incapacity.
Sex Offenses - non-forcible unlawful, non-forcible sexual intercourse and Violence Against Women Act (VAWA). *
Incest - non-forcible sexual intercourse between persons who are related to each other within the degrees wherein marriage is prohibited by law.
Statutory Rape - non-forcible sexual intercourse with a person who is under the statutory age of consent.
VAWA - Violence Against Women Act
Domestic Violence - felony or misdemeanor crimes of violence committed by a current or former spouse of the victim, by a person with whom the victim shares a child in common, by a person who is cohabitating with or has cohabited with the victim, as a spouse, by a person similarly situated to a spouse of the victim under the domestic or family violence laws of the jurisdiction received grant monies, or by any other person against an adult or youth victim who is protected from that person’s acts under the domestic or family violence laws of the jurisdiction.
Dating Violence - committed by a person who is or has been in a social relationship of a romantic or intimate nature with the victim; and where the existence of such a relationship shall be determined based on a consideration of the following factors; the length of the relationship, the type of relationship; the frequency of interaction between the persons involved in the relationship.
Stalking - engaging in a course of conduct directed at a specific person that would cause a reasonable person to; fear for his or her safety or the safety of others; or suffer substantial emotional distress.

Was this a sex offense?

Yes

Was the crime committed forcibly and/or against the victim's will?

Yes

Unknown

Is there evidence that the assault was facilitated by administration of drugs or alcohol?

Yes

Unknown

If you checked "yes" to the previous questions, please explain:

Incident Reporting and Location

Was the incident reported to you by the victim, the offender, or a third party?

Victim

Offender

Third Party

Location of incident: (If the incident occurred in multiple places, please check all that apply)

If the specific location (building name, street address, etc.) is known, please provide it.

Has this been reported to the Lincoln University Title IX Coordinator? *

Yes

Leave this field blank

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