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G FORM CAMPUS SECURITY AUTHORITY REPORTIN (Eastern Florida State College)

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CAMPUS SECURITY AUTHORITY REPORTIN
G FORM
This form is to be used by Campus Security Authorities to report Clery Act crimes to the College.
PLEASE READ INSTRUCTIONS BEFORE USING FORM
If a serious crime that
may cause an imminent or ongoing threat to the College community is reported to you,
immediately call 911. Then call the Campus Security office on the appropriate campus.
If there is any question about whether an ongoing threat exists, immediately contact Campus Security.
1. The Jeanne Clery Disclosure of Campus Security Policy and Campus Crime Statistics Act (the “Clery Act”) requires
certain individuals known as “Campus Security Authorities” or “CSAs” to document any Clery Act crimes reported to
them in good faith occurring (1) on any campus, (2) in or on any public property within or immediately adjacent to and
accessible from any campus, or (3) in or on any non-campus buildings or property owned or controlled by the College.
2. Clery Act crimes are as follows: murder/non-negligent manslaughter, negligent manslaughter, sex offenses
(including rape, fondling, incest, and statutory rape), robbery, aggravated assault, burglary, motor vehicle theft,
domestic violence, dating violence, stalking, arson, liquor law violations, drug law violations and illegal weapons
possession. For definitions of these crimes, please see page 5 of this form.
3. Hate Crimes: CSAs are also required to indicate whether any of the crimes listed in 2 above, or any crimes such
as larceny/theft, simple assault, intimidation, or destruction/damage/vandalism of property were motivated by bias or
prejudice on the basis of the victim’s race, gender, gender identity, religion, sexual orientation, ethnicity, national
origin, or disability.
4. Before receiving information about a Clery Act crime, make sure the person you are speaking with understands that
you are required to forward any information you receive to other College officials, which may result in an investigation
and/or follow up communication.
5. AFTER YOU COMPLETE THIS FORM, IMMEDIATELY SUBMIT A COPY TO EACH OF THE FOLLOWING PERSONS. YOU MAY
SUBMIT VIA FAX, E-MAIL, OR HAND DELIVERY; HOWEVER PLEASE FOLLOW UP WITH A TELEPHONE CALL TO EACH
PERSON TO CONFIRM RECEIPT. IF AFTER HOURS OR CLOSED, SUBMIT THE FORM TO ANY CAMPUS SECURITY OFFICE.
Mark Renkens
Title IX Compliance Coordinator
Melbourne Campus, Bldg. 10, Room 215
Phone: (321) 433-7180
Fax: (321) 433-5026
E-Mail: renkensm@easternflorida.edu
Darla Ferguson
AVP H.R. and Chief Equity & Diversity
Cocoa Campus, Bldg. 2, Room 113
Phone: (321) 433-7080
Fax: (321) 433-7685
E-Mail: fergusond@easternflorida.edu
Joe Ambrose
Chief of Security
Melbourne Campus, Bldg. 8, Room 201
Phone: (321) 433-7007
Fax: (321) 433-5026
E-Mail: ambrosej@easternflorida.edu
1
CAMPUS S
ECURITY AUTHORITY REPORTING FORM
Reporting Person
Are you: CSA who received report of a Clery crime from another person
CSA who was a victim of a Clery crime
CSA who was a witness to a Clery crime
Are you a: Student Employee
Faculty Other_____________
First Name:
Last Name:
Address:
City:
State:
Phone Number:
E-Mail Address:
Date Clery crime was reported to CSA: Time Clery crime was reported to CSA: Location where report was made to CSA:
Victim (if not the same person as the Reporting Person)
Does the Victim wish to remain anonymous?
Yes
No (if the answer is yes, proceed to next section)
Is the Victim a:
Student
Employee
Faculty
Other______________________________________
Victim’s Age:
First Name:
Last Name:
Address:
City:
State:
Phone Number:
E-Mail Address:
Gender:
Race:
Age:
Law Enforcement Information
Was any law enforcement agency notified of the incident? If so, which agency?
Does the Victim want the incident reported to law enforcement? Yes No Unknown
Does the Victim request assistance with reporting the incident to law enforcement? Yes No Unknown
Incident Information
Date of Incident:
Time of Incident:
Location of incident (if incident occurred on EFSC property, identify which campus, building, parking lot, etc.):
Description of incident:
2
Suspect (information about the person accused of committing a Clery Act crime; use “Narrative” section below if
multiple persons)
First Name:
Last Name:
Address:
City:
State:
Zip:
Phone Number:
E-Mail Address:
Gender:
Race:
Age:
Is this person a student, employee, or faculty of EFSC?
Yes
No
Unknown
Is this person an acquaintance of the Victim?
Yes
No
Unknown (if the answer is “yes” describe the relationship between
the Responding Party and the Victim)
Witnesses (information about any witnesses to the crime; use “Narrative” section below if multiple witnesses)
First Name:
Last Name:
Address:
City:
State:
Zip:
Phone Number:
E-Mail Address:
Age of the Witness:
Is this person a student, employee, or faculty of EFSC? Yes No Unknown
Category of Incident (please see “Definitions” below):
Primary Clery Act
Incidents/Crimes
Sexual Incidents
Arrests For
Violation of:
Disciplinary
Referrals for
Violation of:
Additional
“Hate Crime”
Incidents
Other
Murder/Non-
Negligent
Manslaughter
Negligent
Manslaughter
Robbery
Aggravated Assault
Burglary
Motor Vehicle
Theft
Arson
Rape
Fondling
Incest
Statutory Rape
Domestic Violence
Dating Violence
Stalking
Liquor Laws
Dru
g Laws
Weapons
Laws
Liquor Laws
Dru
g Laws
Weapons Laws
Larceny/Theft
Si
mple Assault
Intimidation
De
struction /
Damage /
Vandalism of
Property
I am not
sure how
to classify
this
incident
3
Hate Crimes
Is there any evidence that the incident was motivated by bias/prejudice? Yes No Unknown
If yes, please choose any/all categories of bias/prejudice that apply: N/A
Race Gender Gender Identity Religion Sexual Orientation Ethnicity National Origin
Disability
If yes, please provide a brief summary of the evidence supporting bias/prejudice motivation: N/A
Sexual Incidents
If the incident was sexual in nature, did the Victim receive a copy of the EFSC Sexual Misconduct Resource Guide? Yes No
Unknown N/A (if the answer is “no” please provide the Victim with a copy of the Resource Guide)
If the incident was sexual in nature, did the Victim receive any medical treatment after the incident?
Yes No Unknown N/A (if the answer is “no” please suggest that Victim seek treatment if they need it)
If the incident was sexual in nature, did the Victim preserve any evidence involving the incident?
Yes No Unknown N/A (if the answer is “yes” please describe the evidence below)
If the incident was sexual in nature, did the Victim make any requests for immediate accommodations from EFSC, such as a campus
no-contact order, or changes to academic, living, transportation, and/or working situations? Yes No Unknown N/A (if
the answer is “yes” please describe the requests below)
Narrative (please provide any other information you may have about the incident)
WHERE DOES THIS FORM GO?
WHEN COMPLETED, SUBMIT A COPY OF THIS FORM TO EACH OF THE FOLLOWING PERSONS IMMEDIATELY UPON RECEIVING THE REPORT.
YOU MAY SUBMIT VIA FAX, E-MAIL, OR HAND DELIVERY; HOWEVER PLEASE FOLLOW UP WITH A TELEPHONE CALL TO EACH PERSON TO
CONFIRM RECEIPT. IF AFTER REGULAR HOURS OR WHEN THE COLLEGE IS CLOSED, SUBMIT THE FORM TO ANY CAMPUS SECURITY OFFICE.
Mark Renkens
Title IX Compliance Coordinator
Melbourne Campus, Bldg. 10, Room 215
Phone: (321) 433-7180
Fax: (321) 433-5026
E-Mail: renkensm@easternflorida.edu
Darla Ferguson
AVP H.R. and Chief Equity & Diversity
Cocoa Campus, Bldg. 2, Room 113
Phone: (321) 433-7080
Fax: (321) 433-7685
E-Mail: fergusond@easternflorida.edu
Joe Ambrose
Chief of Security
Melbourne Campus, Bldg. 8, Room 201
Phone: (321) 433-7007
Fax: (321) 433-5026
E-Mail: ambrosej@easternflorida.edu
4
Definitions
Aggravated Assault - An unlawful attack by one person upon another for the purpose of inflicting severe or aggravated bodily injury. This type of assault usually is
accompanied by the use of a weapon or by means likely to produce death or great bodily harm. (It is not necessary that injury result from an aggravated assault when
a gun, knife, or other weapon is used which could and probably would result in serious personal injury if the crime were successfully completed.)
Arson - Any willful or malicious burning or attempt to burn, with or without intent to defraud, a dwelling house, public building, motor vehicle or aircraft, personal
property of another, etc.
Burglary - The unlawful entry of a structure to commit a felony or a theft. For reporting purposes this definition includes: unlawful entry with intent to commit a larceny
or felony; breaking and entering with intent to commit a larceny; housebreaking; safecracking; and all attempts to commit any of the aforementioned.
Dating Violence - Violence committed by a person who is or has been in a social relationship of a romantic or intimate nature with the victim.
(i) The existence of such a relationship shall be determined based on the reporting party’s statement and with consideration of the length of the relationship, the type
of relationship, and the frequency of interaction between the persons involved in the relationship.
(ii) For the purposes of this definition—
(A) Dating violence includes, but is not limited to, sexual or physical abuse or the threat of such abuse.
(B) Dating violence does not include acts covered under the definition of domestic violence.
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 or the person having custody or control of it.
Domestic Violence - A felony or misdemeanor crimes of violence committed by a current or former spouse of the victim, or by a person with whom the victim shares
a child in common, or by a person who is cohabitating with or has cohabitated with the victim as a spouse, or by a person similarly situated to a spouse of the victim
under the domestic or family violence laws of Florida, or by any other person against an adult or youth victim who is protected from that
person’s acts under the
domestic or family violence laws of Florida.
Drug Laws (Arrests & Disciplinary Referrals) - The violation of laws prohibiting the production, distribution, and/or use of certain controlled substances and the
equipment or devices utilized in their preparation and/or use. The unlawful cultivation, manufacture, distribution, sale, purchase, use, possession, transportation, or
importation of any controlled drug or narcotic substance. Arrests for violations of State and local laws, specifically those relating to the unlawful possession, sale, use,
growing, manufacturing, and making of narcotic drugs.
Fondling - The touching of the private body 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.
Incest - Sexual intercourse between persons who are related to each other within the degrees wherein marriage is prohibited by law.
Intimidation - To unlawfully place another person in reasonable fear of bodily harm through the use of threatening words and/or other conduct, but without displaying
a weapon or subjecting the victim to actual physical attack.
Larceny-Theft - The unlawful taking, carrying, leading, or riding away of property from the possession, or constructive possession, of another.
Liquor Laws (Arrests or Disciplinary Referrals) - The violation of state or local laws or ordinances prohibiting the manufacture, sale, purchase, transportation, possession,
or use of alcoholic beverages, not including driving under the influence and drunkenness.
Motor Vehicle Theft - The theft or attempted theft of a motor vehicle.
Murder and Non-Negligent Manslaughter - The willful (non-negligent) killing of one human being by another.
Negligent Manslaughter - The killing of another person through gross negligence.
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.
Robbery - The taking, or attempting to take, anything of value from the care, custody, or control of a person or persons by force or threat of force or violence and/or
by putting the victim in fear.
Simple Assault - An unlawful physical attack by one person upon another where neither the offender displays a weapon, nor the victim suffers obvious severe or
aggravated bodily injury involving apparent broken bones, loss of teeth, possible internal injury, severe laceration, or loss of consciousness.
Stalking - Engaging in a repetitive course of conduct directed at a specific person that would cause a reasonable person to fear for his or her safety or the safety of
others; or suffer substantial emotional distress. For purposes of this definition:
Course of conduct means two or more acts, including, but not limited to, acts in which the stalker directly, indirectly, or through third parties, by any action, method,
device, or means, follows, monitors, observes, surveils, threatens, or communicates to or about a person, or interferes with a person’s property.
Reasonable person means a reasonable person under similar circumstances and with similar identities to the victim.
Substantial emotional distress means significant mental suffering or anguish that may, but does not necessarily, require medical or other professional treatment or
counseling.
Statutory Rape - Sexual intercourse with a person who is under the statutory age of consent.
Weapons Laws (Arrests or Disciplinary Referrals) - The violation of laws or ordinances prohibiting the manufacture, sale, purchase, transportation, possession, concealment,
or use of firearms, cutting instruments, explosives, incendiary devices, or other deadly weapons.
5
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G FORM CAMPUS SECURITY AUTHORITY REPORTIN (Eastern Florida State College)

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Completed 15 August 2020

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