Revised 01/2015
CSA CRIME REPORT CLOSEOUT FORM
The Campus Security Authority (CSA) Crime Report Closeout Form must accompany any additional crime
reports that were not included in previous submissions. If you do not have any additional crime reports
to submit, please select the appropriate checkbox, sign, and date the form.
Completed forms are to be submitted to: Vice Chancellor of Administrative Services
Administration Building, Room 112
SECTION I. To be completed by Campus Security Authority (CSA).
CAMPUS: Leeward Community College
SUBMISSION DATE: ________________________
CSA NAME: ______________________________ PHONE: _____________
CSA DIVISION/UNIT: ______________________________ EMAIL: _________________________
CHECK ONE:
☐ Additional Crime Reports Attached; Total of ____ Reports
☐ CSA Has No Additional Crime Reports Or Statistics To Submit
COMMENTS/NOTES: _________________________________________________________________
_________________________________________________________________
CSA SIGNATURE _______________________________________
SECTION II. To be completed by Vice Chancellor of Administrative Service Office.
DATE RECEIVED: ________________________
BY (NAME): _____________________________
