SUNY Cobleskill
Crime Incident Report Form
This form should be completed by those individuals identified as “campus security
authorities” who are required to report information they receive about specified crimes
(described below) pursuant to the federal Clery Act. The information collected from these
forms will be used to prepare a compilation of statistical crime information that will be
included in the campus’ Annual Security Report.
It is the policy of the State University of New York to ensure that victims and witnesses
to crimes are aware of their right to report acts to the police, and to report University
policy violations to the appropriate office. However, if a reporting person requests
anonymity, this request must be honored to the extent permitted by law. Accordingly, no
information should be included on this form that would personally identify the victim
without his/her consent.
University Police will use this form to determine the category of crime and location under
which the crime should be reported according to the requirements of the Clery Act.
Please forward this completed form to:
Chief of University Police
Johnson Hall
*Crimes that are required to be reported are: Murder, Manslaughter, Sex Offenses,
Robbery, Burglary, Aggravated Assault, Arson, and Motor Vehicle Theft and Hate
Crimes. Hate Crimes include any of the aforementioned crimes, and the following
crimes, larceny, simple assault, intimidation, and destruction, damage or vandalism
of property that show evidence of hate motivation and that the victim was selected
because of actual/perceived race, gender, religion, national origin, disability, or
sexual orientation. Domestic Violence, Dating Violence and Stalking
Person Receiving Report: ________________________ Phone: _________________
Report Made by:
Third Party Please identify relationship to victim: ________________________
Date and Time the Incident occurred: ________________________________________
Description of the Incident or Crime:
Location of Incident
Identify building name, address, etc.; be specific as possible:
The location where this incident occurred was:
On campus, but not in student housing
On campus student housing
Off-campus affiliated property
Off-campus public property immediately adjacent to campus
Off-campus, NOT affiliate with or not adjacent to campus
Sex Offense
Was the crime a sexual offense? Yes No
If yes, were the victim and the assailant acquainted? Yes No
If yes, were either the victim or the assailant under the influence of alcohol or drugs?
Victim: No Yes – alcohol Yes - drugs
Assailant: No Yes – alcohol Yes - drugs
Hate Crimes
Was the incident motivated by hate or bias? Yes No
If yes, identify the category of prejudice:
Race Gender Ethnicity National Origin
Religion Disability Sexual Orientation Gender Identity
If yes, provide a brief explanation of the determination:
Domestic Violence, Dating Violence or Stalking
Relationship to Victim:
Acquaintance Intimate Partner Unknown Individual
Description of the Incident or Crime:
Alcohol, Drug and Weapons Violations
Check all that apply
Alcohol Drugs Weapons, describe_______________________
Number of individuals arrested or referred for campus disciplinary action: __________
Signature______________________________ Date___________________________