California State University, Channel Islands
Campus Security Authority
Jeanne Clery Act Statistics
Clery Crime Report
According to the Higher Education Act, or 20 U. S.C. 1092 – now known as the Jeanne Clery Disclosure of Campus
Security Policy and Campus Crime Statistics Act, California State University, Channel Islands must collect and report
certain campus crime statistics. This law applies to specific crimes reported to the police and other campus officials.
The details of this report will not be made public. Only the number of crimes occurring will be released. Your name will
not be released. It is not required for the report, but it will help ensure the crime is not counted twice.
Date of incident: _____ / _____ / __________
Time of occurrence: __________ AM / PM
Location of crime: _____________________________________________________________. Provide the
building name, parking lot number, street name with cross streets or close address, or nearby buildings. Use a CSU
Channel Islands campus map and circle location if necessary.
□ Non-Campus Property
□ Public Property
Other Crime Bodily Injury
Vandalism
Threats
Simple Assault
Theft
□ Robbery
□ Sex offense
□ Vehicle theft □ Arson
□ Stalking
Arson
Motor Vehicle
Theft
Burglary
□ Manslaughter
□ Burglary
□ Dating violence
Aggravated
Assault
Hate Crimes
Enter the total
number in the
appropriate box to
indicate type of
crime and bias
□ Residence Hall
Robbery
□ Murder
□ Aggravated assault
□ Domestic violence
Sex Offenses
Crime being reported:
Manslaughter
□ On-Campus
Murder
Location Classification:
Race
Gender
Gender Identity
Religion
Sexual Orientation
Ethnicity
National Origin
Disability
Law enforcement agency(s) the incident has been reported to:
□ CSU Channel Islands Police Department
□ Other____________________
□ None
□ Ventura County Sheriff’s Department
Police report number: _________________
Please give a brief description of the crime to assist in proper classification. Please use back of form or separate
page, if necessary:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Name of Campus Security Authority: ______________________________________________________________
Phone #: ______________________________ Email: _________________________________________________
Department____________________________________________________ Date: __________________________
REVISED: June 2014