California State University, Channel Islands
Campus Security Authority
Jeanne Clery Act Statistics
Disciplinary Referral 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.
In accordance with the Jeanne Clery Act, statistics must be collected and reported for campus crimes categorized as
Liquor Law Violations, Drug Violations, and Weapons Violations that were referred within the University for
disciplinary purposes. For this purpose, Liquor Law Violations, Drug Violations, and Weapons Violations are
defined as follows:
Liquor Law Violations
The unlawful possession, sale, transportation, manufacturing of alcoholic beverages, furnishing alcohol to a minor
(under 21 years), or maintaining an unlawful drinking place. CLERY does not require the reporting of public
drunkenness or driving while under the influence offenses.
Drug Violations
The unlawful possession, use, sale, purchase, transportation, cultivation, or manufacturing of any narcotic or controlled
substance, or the equipment or devices utilized in their preparation and/or use.
Weapons Violation
The unlawful possession or control of any firearm, deadly weapon, (including nunchakus or billy club) illegal knife, or
explosive device while on the property of California State University, Channel Islands except as required in the lawful
course of business or as authorized by the CI President.
Please complete a separate Disciplinary Referral Report for each incident.
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 CI
campus map and circle location if necessary.
Location Classification:
□ On-Campus
Disciplinary Referral (select one)
□ Residence Hall
□ Liquor Law Violation
□ Non-Campus Property
□ Drug Violation
□ Public Property
□ Weapons violation
By whom disciplinary action was referred? ___________________________________ Phone #: _______________
(PRINT FIRST AND LAST NAME)
Number of violators (head count) for Liquor / Drug / Weapon violations: _______________
Please give a brief description of the crime to assist in proper classification (Example: Underage drinking – Must
include the number of violators and their dates of birth. Please use back of form or separate page, if necessary):
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Name of Campus Security Authority: ______________________________________________________________
Phone #: ______________________________ Email: _________________________________________________
Department____________________________________________________ Date: __________________________