North Idaho College has an expectation that employees will share information they receive about campus crime. This
form is intended to convey information needed to track the College’s response to campus incidents being reported, as
well as to assess the danger the incident represents to the community at large. Annual statistical information will be
based on this report, as will the need to make timely warnings to the community, for the protection of those who may
be at risk.
Instructions: Fill in all fields that apply. Report only one incident per form. Take more space than is given on this form,
as necessary, to complete the descriptions. You should return this form to Alex Harris, director of student
development/Title IX coordinator (, as well as campus security ( within 24 hours
of becoming aware of an incident. You may also wish to include your supervisor.
Your name:
Reported to you by :
victim witness third-party anonymous
Date of report:
Time of incident:
Location of incident:
If you wish to avoid specifics regarding the location, please indicate one of the following
(Please see descriptions of these four categories on reverse of this page, for proper classification):
On campus Residence Hall Public Property Off campus Other
Please describe the incident in as much detail as possible:
Do you have reason to believe this incident represents a present threat of harm or danger
to the victim or other member(s) of the community?
If Yes, why?
Was a weapon involved?
Yes No
Number of perpetrators/assailants:
If a single assailant/perp,
Role of assailant/perp(s) on
Student Staff Faculty No campus role Unknown
Name of alleged assailant(s):*
Was there any evidence that this incident was motivated by the victim’s (check all that apply):
Race Ethnicity Age
Gender Sexual orientation Religion None of these
Other departments or individuals to whom the victim/reporter has reported this incident:
Name of reporting victim *
Names and contact information for any relevant witnesses*
* Any field denoted with an asterisk is a field that may be left blank by you if you intend for this report not to serve as actual
notice to the college of harassment, discrimination, sexual assault or other civil rights violation for which notice will trigger an
obligatory investigation by the college. Some employees are required to complete this form in full, while others may withhold from
the fields designated with a *, depending on your role.