Crime Incident Report Form

This form should be completed by those individuals identified as "campus safety/security authorities" who are required to report information they receive about specified crimes (described below) pursuant to the federal Clery Act. The information collected from these forms will be used to prepare a compilation of statistical crime information that will be included in the campus Annual Security Report.

It is the policy of College of the Canyons to ensure that victims and witnesses to crime are aware of their right to report criminal acts to the police, and to report COC policy violations to the appropriate office. However, if a reporting person requests anonymity, this request must be honored to the extent permitted by law. No information should be included on this form that would personally identify the victim without his/her consent.

Campus Safety will use this form to determine the category of crime and location under which the crime should be reported according to the requirements of the Clery Act.

Please forward this completed form to:

Campus Safety/Security

26455 Rockwell Canyon Road

Santa Clarita, Ca. 91355

Attention: Director of Campus Safety

Person Receiving Report: _______________________________

Phone Number: __________________

Report Made by:

_____________________________Victim

_____________________________Third Party

Please identify relationship to victim:

____________________________________________________

Date and Time the Incident occurred:

_____________________________________________________

Description of the incident or crime:

________________________________________________________________________

Location of Incident

Identify building name, address, etc.; be as specific as possible): ________________________________________________________________________

________________________________________________________________________

The location where this incident occurred was:

______________________________________ On campus or off

_________________________ Off-campus affiliated property (owned, controlled, or affiliated with the campus; e.g., leased property, fraternity, student co-op)

______ Off-campus public property immediately adjacent to campus

______ Off-campus, NOT affiliated with or not adjacent to campus

______ Unknown

Sex Offenses

Examples of sex offenses are rape, sodomy, sexual assault with an object, fondling, incest, and statutory rape.

Was this crime a sexual offense ? ______ Yes ______ No

Did it involve dating violence? _______ Yes ________No

Did it involve domestic violence? ______Yes ______No

Did it involve stalking? _____Yes _____No

If yes, were the victim and the assailant acquainted? ______ Yes ______ No

If yes, were either the victims or the assailant under the influence of alcohol or drugs?

Victim: ______ No Yes, alcohol ______ Yes, drugs _____

Assailant: ______ No Yes, alcohol ______ Yes, drugs _____

Hate Crimes

Hate crime information is required to be reported for each of the following crimes (criminal homicide, sex offense, robbery, aggravated assault, burglary, motor vehicle theft, and arson) and for any other crime involving bodily injury.

Was this incident motivated by hate or bias? ______ Yes ______ No

If yes, identify the category of prejudice:

______ Race ______ Ethnicity ______ National Origin

______ Religion ______ Disability ______ Sexual Orientation

If yes, provide a brief explanation of the determination: ________________________________________________________________________

Alcohol, Drug and Weapons Law Violations

Check all that apply:

______ Alcohol ______ Drugs ______ Weapons Describe: ________________

Number of individuals arrested or referred for campus disciplinary action: _________________