University of Kentucky Office of Crisis Management
Campus Security Authority Incident Form
This information is provided to meet the requirements of the Jeanne Clery Disclosure of Campus Security Policy and Campus Crime Statistics Act of
This information is provided to meet the requirements of the Jeanne Clery Disclosure of Campus Security Policy and Campus Crime Statistics Act
of 1998 and the Kentucky Postsecondary Education Campus Security (Minger) Act of 2000. Submission of this report does not constitute an
official Police Report and will not result in any further investigation by law enforcement personnel unless the reported act is an immediate threat
to the safety or well-being of a student or the University community.
CSA Information:
Campus Security Authority Name:
Report Date:
E-Mail:
Phone Number:
Ext:
Incident Information:
Date of Incident:
Time of Incident:
Location of Incident:
Type of Incident: Crime Definitions
Arson
Menacing
Sex Offense
Theft
(Rape, Fondling)
Assault
Motor Vehicle Theft
Burglary
Murder
Wanton Endangerment
Other Sex Offenses
Weapons Possession
(Statutory Rape, Incest)
Criminal Damage to Property
Reckless Homicide
Stalking
Domestic Violence
Manslaughter
Robbery
Terroristic Threatening
Dating Violence
Liquor Law Violations (Minor in Possession, Furnishing Liquor to a Minor)
Was this incident reported to the police, or any other CSA?
Yes
Drug Abuse Violation
No
If yes, to who?
Was the crime perceived to be motivated by hate?
If yes, by what bias?
Disability
Ethnicity
National Origin
Gender
Yes
No
Gender Identity
Race
Religion
Sexual Orientation
Detailed description of incident (Required):
When you have completed this form, please attach to an email and send to cmp@uky.edu or fax to Crisis Management and Preparedness at
(859) 257-4143.