Campus Security Authority Reporting Form

* All required fields are marked with an asterisk.

Date of report *

Name of campus security authority *

Email of campus security authority *

Date that incident occurred

If multiple incidents were reported or if the date of the incident is unknown, please add note

Last four digits of victim's UTDID number *

Reported by *

Reporting person's name *

Reporting person's phone number

Reporting person's Email address

If a third party reported the crime to you, please enter the relationship of the third party to the victim

If, to your knowledge, a law enforcement agency was notified, please enter the name of that agency.

Does the victim want the incident
investigated by law enforcement? *

Does the victim want the incident
investigated by the Dean of Students? *

Time of incident (if known)

Incident description (Please provide specific, detailed information) *

Incident Categories (check all that apply) *

Aggrevated Assault
Sex Offense (forcible)
Sex Offense (non-forcible)
Dating Violence
Arrest for Liquor Law Violation
Arrest for Drug Law Violation
Arrest for Weapons Law Violation

Motor Vehicle Theft
Domestic Violence
Hate Crime (see below for details)
Referral for Liquor Law Violation
Referral for Drug Law Violation
Referral for Weapons Law Violation

If the crime was not listed above, please enter the additional crime category:

I am not sure how to classify this incident.
Please provide as much information as possible so that campus personnel can make this determination.

Is there any evidence that this crime was motivated by bias? *
Yes No

If yes, please choose all categories of prejudice that apply:



National Origin

Gender Identity
Sexual Orientation

If you answered "yes" to the Motivated by Bias question, please provide a brief summary of the evidence supporting a bias motivation:

Did this incident occur on campus or off campus? *
On Campus
Off Campus

Specific Location on Campus (if applicable)