CSA Name/Dept. /
Print Name Print Dept.
“Campus Security Authority Closeout Form for 2018"
According to the Jeanne Clery Disclosure of Campus Security Policy/Campus Crime Statistics Act, the University of Hawai`i at Hilo must collect
certain campus crime statistics. All designated Campus Security Authorities (CSAs) are required to report any crimes that they are aware of which might
not have been officially reported to the University.
If you are not aware of any unreported crimes in 2018, please check the box below and sign your name. Federal law
requires written documentation that NO crimes were reported to you during the previous calendar year.
By placing an X in this box, you are certifying that no “Clery” crimes, as listed below, were reported to you that were not reported to Campus
Security during 2018
.
Signature: Date:
Please refer to URL https://hilo.hawaii.edu/security/CaseDescriptions.php for more detailed descriptions of crimes.
If anyone reported a crime to you in 2018 that appears on the list below and to your knowledge might not
have been reported to Campus Security, please fill out the appropriate data below. The object of this form
and your responsibility are to ensure UH Hilo is recording the actual number of alleged crimes that occur on
or near the University throughout the year. Names should not be reported, but Federal law requires the
crime itself be reported.
Date reported: Date/time of crime: Location:
Use a UHH campus map and circle location if necessary.
Crime:
Crime:
Hate Crime: Sex Offense:
Murder Motor Vehicle Theft Larceny Rape
Manslaughter Drug Violation Intimidation Fondling
Arson Liquor Law Violation Simple Assault Sodomy
Burglary Weapon Violation Vandalism Incest
Robbery Terroristic Threat Assault w/object
Aggravated Assault
(Note: Any rape that is “forcible” is categorized as “rape.” Statutory rape depends on age of victim and suspect. If you need
assistance with any classification, contact Campus Security at 974-7911.)
Please give a brief description of the crime/incident:
Check appropriate box if a Hate Crime:
Race
Gender Religion Sexual Orientation Ethnicity Disability
Additional Information:
Date Submitted:
Phone: E-mail:
Please submit this form to UH Hilo Campus Security (UCB, 301-151) and keep a copy for your records. If you have questions about
classifying a crime or a location, contact the Director of Campus Security at 932-7644, or via e-mail to uhhsafe@hawaii.edu.
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