Fillable Kellogg Community College Campus Security Authority - Jeanne (Kellogg Community College)

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Kellogg Community College Campus Security Authority - Jeanne (Kellogg Community College)

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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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Kellogg Community College Campus Security Authority - Jeanne (Kellogg Community College)

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Completed 26 July 2020

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