Fillable CLERY ACT CRIME/INCIDENT REPORTING FORM (Millersville University of Pennsylvania)

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CLERY ACT CRIME/INCIDENT REPORTING FORM (Millersville University of Pennsylvania)

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CLERY ACT
CRIME/INCIDENT REPORTING FORM
This form shall be completed by those persons identified under the federal law known as
the “Clery Act” as
campus security authorities who are required to report information they
receive regarding specific crimes. All other members of the campus community NOT
included in the category of
campus security authorities are strongly urged to report
information about known or suspected criminal activity to the Millersville University
Police. The information collected is used in the compilation of statistical crime information
that will be included in the campus Annual Security Report.
It is the policy of Millersville University to ensure that victims of crime 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. However, if a reporting person requests
anonymity, this request shall be honored to the extent allowed by law. Additionally, no
information should be included on this form that would personally identify any victim
without his/her consent.
Millersville University Police will use this form to determine the category and location of
the crime, and if the crime should be recorded under the Clery Act. Please e-mail the
completed form to Lt. Arthur White (arthur.white@millersville.edu) and Chief
Peter Anders (peter.anders@millersville.edu), or if unable to scan and e-mail, please
mail to Attn: Lt. Art White/Chief Peter Anders at Millersville University Police, Lebanon
House, Millersville, PA. 17551.
PLEASE PRINT
Person Filing Report _________________________________ Date ____________________
Report Made By: _______Victim ________ Third Party ___________ Other
Date and Time Incident Occurred ________________________________________________
Location of Incident (be as specific as possible)____________________________________
Location _______On Campus (not in Residence Hall) ________ Campus Housing
_______Off Campus (adjacent to campus) ________ Off Campus (not adjacent)
Sex Offense ______YES ______NO
Was the incident apparently motivated by hate or bias? _____YES ______NO
Description of Incident or
Crime:_______________________________________________________________________
_____________________________________________________________________________
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CLERY ACT CRIMEINCIDENT REPORTING FORM (Millersville University of Pennsylvania)

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Completed 23 July 2020

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