Kellogg Community College
Campus Security Authority - Jeanne Clery Act
CRIME AND DISCIPLINARY REFERRAL REPORT FORM
DATE OF CRIME: ______________________ TIME OF CRIME: _____________________
LOCATION OF INCIDENT: ________________________________________________________
LOCATION CLASSIFICATION: On-Campus Non Campus Building/Property
Public Property
CRIME: Murder Manslaughter Sex Offense-forced Sex Offense Non-forced
Robbery Burglary Aggravated-Assault Vehicle Theft
Arson Narcotics Alcohol Violation Weapon Offense
Hate Crime Theft Vehicle Accident Other _______________________
HATE CRIME: HATE CRIME BASED ON:
Yes No Race Gender Religion
Sexual Orientation Ethnicity Disability
Discipline Referral or Arrest for Liquor, Drug or Weapon Violations:
Arrest Liquor Violation Weapon Violation
Discipline Referral Drug Violation
Discipline Referral To: _______________________________________________________________
REPORTING PERSON: Victim Witness Third Party Perpetrator
Name _______________________________________________________________________
LAW ENFORCEMENT AGENCIES THE INCIDENT HAS BEEN REPORTED TO:
Kellogg Community College DPS Battle Creek PD Other______________ None
According to the Higher Education Act or 20 U.S.C. 1092 now known as the Jeanne Clery Disclosure of
Campus Security Policy and Campus Crime Statistics Act, Kellogg Community College must collect certain
campus crime statistics. This law applies to certain crimes reported to the Campus Safety Department and
other campus officials.
The details of this report will not be made public. Only the number of crimes occurring will be released.
Your name will not be released. It is not required for the report, but it will help ensure the crime is not
counted twice.
Kellogg Community College
Please turn in completed forms to Kellogg Community College Dept. of Public Safety.
Room 306 Lane Thomas Building at the main campus of Kellogg Community College
450 North Ave. Battle Creek, Mi. 49017
SUMMARY OF INCIDENT
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REPORT PREPARED BY: __________________________________________________________
Name Position Date
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