Clery Act

To assist Austin Peay State University in complying with the federal Clery Act, this form should be utilized by Campus Security Authorities (CSA) to report crimes to Austin Peay Campus Police as soon as possible after a crime has been reported to the CSA. Under the Clery Act, a crime is reported to a CSA when a student, employee, or third party brings information about an alleged crime to the attention of the CSA and the CSA believes the report was made in good faith. Austin Peay Campus Police will use the information provided in this form to classify the crime for purposes of inclusion in the University’s annual crime statistics.

Date Incident Reported to CSAMM/DD/YYYY

First Name *First name

Last Name*Last name

DepartmentDepartment you are from

Phone *Best phone number to contact you

E-mailBest email address to contact you

Date Incident Occurred

Incident Location Name / AddressWhere did the incident occurr?

Classification (Select One)*

On-campus, residence hall, fraternity or sorority

On-campus, not in a residence hall

Off-campus, public property immediately adjacent to campus (sidewalks, streets, etc)

Off-campus in University leased or controlled space

Off-campus, not affiliated with and not adjacent to campus

Unknown location

Did the incident occur in a building or on the street?

Did the incident occur at a university owned sponsored activity?

Did the incident occur on university owned, controlled or leased property?

To your knowledge, was this incident motivated by bias such as:

Race

Gender

Ethnicity

Sexual Orientation

Religion

Disability

Please describe evidence supporting the conclusion that the incident was motivated by bias:

To your knowledge, was this incident reported to an agency and if so which one?