Campus Security Authority:
Crime & Incident Report Form
Page 1 of 4
Any individual who suspects or has knowledge that a crime has been committed can report such crime at
any time to the appropriate law enforcement agency.
INSTRUCTIONS: Employees designated as a Campus Security Authority (CSA) must complete
this form and forward it to Edwin Lovett, USF Tampa Police Department, via e-mail at
or mail point UPB002. For questions regarding this form and for Divisions that
report a large number of alcohol related incidents, please contact Edwin Lovett to discuss
approaches for more efficient provision of this information by calling 813-974-3959.
Last Name, First Name:
Phone #:
Did you receive knowledge of this incident through another department?
No Yes, please indicate which department:
Date of Incident:
Time of Incident:
Date this incident was reported to you:
Describe the incident in detail. This will be used to aide in determining the proper classification under the
Jeanne Clery Act and will aide in our identification of duplicate reporting.
Was this incident reported to the police?
No Unknown Yes, it was reported to the following agency:_____________________ Report Number: __________________
For the following crimes where the police were not present or contacted, please indicate how many
persons were referred for each category and whether or not the same person was referred for multiple
crimes (check all that apply):
Alcohol Referral for Disciplinary Action How many? _________________
(Do Not Include Drunk in Public incidents)
Drug Referral for Disciplinary Action How many? __________________
Weapon Referral for Disciplinary Action How many? __________________
Campus Security Authority:
Crime & Incident Report Form
Page 2 of 4
To the best of your knowledge, what crimes were attempted or committed during this incident
(Check all that apply):
Negligent ManslaughterThe killing of another
person through gross negligence
Sex Offense Under the VAWA and Clery, sex offenses (rape, fondling, incest, or statutory rape) are defined and reported
in accordance with the FBI’s Uniform Crime Reporting Program* as follows:
Rape ― The penetration, no matter how slight, of the vagina or anus with any body part or object, or oral penetration by a sex
organ of another person, without the consent of the victim.
Note: Under State of Florida Statutes, sexual battery is defined as follows: Oral, anal, or vaginal penetration by, or union
with, the sexual organ of another or the anal or vaginal penetration of another by any other object; however, sexual
battery does not include an act done for bona fide medical purpose. “Consent” - means intelligent, knowing, and
voluntary consent and does not include coerced submission. “Consent” shall not be deemed or construed to mean the
failure of the alleged victim to offer physical resistance to the offender.
Fondling ―The touching of the private parts of another person for the purpose of sexual gratification, without the consent of
the victim, including instances where the victim is incapable of giving consent because of his/her age or because of his/her
temporary or permanent mental incapacity.
Incest ― Sexual intercourse between persons who are related to each other within the degrees wherein marriage is prohibited
by law.
Statutory Rape ― Sexual intercourse with a person who is under the statutory age of consent.
*The definition of rape is from the Summary Reporting System (SRS) User Manual; whereas, the definitions of fondling,
incest, and statutory rape are from the National Incident-Based Reporting System (NIBRS) User Manual. Both of these
manuals are from the FBI’s Uniform Crime Reporting Program.
BurglaryUnlawful entry into a structure to commit a
felony or theft
ArsonWillful or malicious burning/attempt to burn
structure, vehicle, or personal property of another
Other crime (indicate the crime type below):
Dating Violence Violence between individuals who have or have had a continuing and significant relationship of a
romantic or intimate nature. The existence of such a relationship shall be determined based on the consideration of the
following factors:
1. A dating relationship must have existed within the past 6 months;
2. The nature of the relationship must have been characterized by the expectation of affection or sexual involvement
between the parties; and
3. The frequency and type of interaction between the persons involved in the relationship must have included that the
persons have been involved over time and on a continuous basis during the course of the relationship.
The term does not include violence in a casual acquaintanceship or violence between individuals who only have engaged in
ordinary fraternization in a business or social context.
Campus Security Authority:
Crime & Incident Report Form
Page 3 of 4
Domestic Violence Any assault, aggravated assault, battery, aggravated battery, sexual assault, sexual battery,
stalking, aggravated stalking, kidnapping, false imprisonment, or any criminal offense resulting in physical injury or death
of one family or household member by another family or household member.
Stalking A person who willfully, maliciously, and repeatedly follows, harasses, or cyberstalks another person commits
the offense of stalking.
Bias or Hate Crimes: (only complete this section when the crime was motivated by hate or bias)
Larceny-TheftThe unlawful taking, carrying,
leading, or riding away of property from the
possession or constructive possession of another
IntimidationTo unlawfully place another person in
reasonable fear of bodily harm through the use of
threatening words and/or other conduct
Simple AssaultAn unlawful physical attack by
one person upon another where neither the offender
displays a weapon
Destruction/Damage/Vandalism of Property
To willfully or maliciously destroy, damage, deface, or
otherwise injure real or personal property without the
consent of the owner
Is there evidence that the victim was specifically targeted because of hate or bias?
Yes. Please indicate all categories of bias that apply to this incident (choose at least one):
Gender Identity
Sexual Orientation
National Origin
Describe the specific hate or bias action or speech:
Note: The above the crime definitions are meant to be a quick-reference guide and are not meant to substitute for the
official definitions provided in the Federal Bureau of Investigation (FBI) Uniform Crime Reporting handbooks or in
statutes/ordinances governing local jurisdictions.
Campus Security Authority:
Crime & Incident Report Form
Page 4 of 4
What best describes the location of the crime? ___________________________________________________________
Be as specific as possible: An address, building or business name, office/room number, intersections, city, name of streets, etc.
Location Type: ________________________________________________________________________________
Resident hall room, office, street, driveway, USF Shuttle, city bus, apartment, hallway, sidewalk
Choose one of the following:
On Campus
All Campus Buildings, Parking Lots, Fields, Roadways
Non-Campus Building or Property
Leased Building Space or Land (Raymond James Stadium, CAMLS, etc.)
On Campus Housing
Resident Halls (Juniper/Poplar, Magnolia Apartments,
Betty Castor Hall, Epsilon, Beta, etc.)
Public Property
Immediately adjacent property to the campus (Fowler Ave., Fletcher Ave,
St., Bruce B. Downs Blvd.)
IMPORTANT REMINDER: It is the policy of the University of South Florida to ensure that the victims and
witnesses to crime are aware of their right to report criminal acts to the police and to report University policy
violations to the appropriate office (e.g. student conduct violations to the Dean of Students). However, if a
reporting person requests anonymity, this request must be honored to the extent permitted by law. Accordingly, no
information should be included on this form that would personally identify the victim without his/her consent.
Based on information received, USFPD will determine the category of the crime or incident and the location under
which the incident should be reported in the Annual Security Report. Clery and associated legislation requires that
each department’s records related to the Clery reportable crime statistics be retained for seven years.
Was this incident previously counted? By whom?
Police Report # ___________________________ Agency: _________________________________
Clery Crime: _________________________________________________________________________________
Clery Location: _______________________________________________________________________________
Number of Incidents Counted: __________