Fillable Anonymous Form (Central Connecticut State University)

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Anonymous Form (Central Connecticut State University)

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Central Connecticut State University
Police Department
Anonymous Crime Report Form
This form is for reporting crimes anonymously to both the CCSU Police Department and other University Departments as needed.
The information in this form will assist in the compilation of statistical records for crimes that occur on the CCSU campus or
surrounding area in compliance with federal and State laws and Board of Regents policies. A person who has been a victim of a
crime may fill out this form him/herself or may ask a third party (such as a friend or a counselor) to do so. If this is an emergency
please call 9 1 1
I. INFORMATION ON THE VICTIM/SURVIVOR
Today's Date
Date/Time of Crime
Male Female
>Affiliation to CCSU
Student
Employee
Visitor
>Residence
Campus Housing Off Campus
> Drug or Alcohol involved?
> Race / Ethnicity:
Type of Crime:
(check all that apply)
Murder/Non-negligent manslaughter
Negligent manslaughter
Forcible sex offenses (including rape)
Burglary/Robbery Arson
Motor vehicle theft
Drugs Alcohol Both
Sexual offences
Assault
If other, please
explain.
Other
Location of crime
Describe
Incident
9/2/15
3. INFORMATION ON THE ACCUSED:
> Number of Accused
> Sex of Accused:
Male Female Both
> Affiliation of Accused to CCSU:
Student
Employee
Visitor
Unknown
> Age of Accused:
> Race / Ethnicity of Accused
> Accuser's Relationship
to the Victim
ADDITIONAL
NOTES /
COMMENTS
If you are unsure about what to do and need immediate assistance the YWCA Sexual Assault Crisis Service offers confidential around
the clock assistance (860) 223-1787.
Presence of Weapon
Unknown
Threat of Death Verbal Other
Name of Accused:
**" While the CCSU Police reserve the right to investigate all allegations, if name of the accused is provided, the CCSU Police will
further investigate."
Residence of Accused
**If the victim would like this further investigated please contact the CCSU Police at (860) 832-2375
Below is a list of resources the victim may use:
Office of Diversity & Equity: (860) 832-0178
http://www.ccsu.edu/diversity
Student Affairs: (860) 832-1601
http://web.ccsu.edu/studentaffairs
Human Resources: (860) 832-1756
http://web.ccsu.edu/hr
YWCA Sexual Assault Crisis Services: (860) 223-1787
http://ywcanewbritain.org
Academic Affairs: (860) 832-2129
http://web.ccsu.edu/academics/academicaffairs/default.asp
CCSU Women's Center: (860) 832-1655
http://web.ccsu.edu/boyea
CCSU Counseling and Wellness Center Services: (860) 832-1945
http://web.ccsu.edu/counselingandwellnesscenter
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Completed 19 July 2020

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