Seattle University
Campus Security Authority (CSA) Incident Report Form
The Jeanne Clery Disclosure of Campus Security Policy and Campus Crime Statistics Act, 20 U.S.C. §1092(f), (the “Clery
Act”), requires Seattle University to collect and disclose certain crime statistics. This law applies to certain crimes
reported to the Department of Public Safety (“DPS”) and other campus officials, known as Campus Security Authorities
("CSA"). Under the Clery Act, CSAs are required to report, on a timely basis, any qualifying crimes that they are aware
of to DPS. Please contact DPS at (206) 296-5990 for additional information on the CSA role and responsibilities.
Only the number, type and location of crimes will be disclosed as part of the University’s crime statistics. Specific details
contained in this form will not be made public.
This PDF form may be filled using Adobe Acrobat Reader. For instructions on how to submit this form, see page (3).
I. CSA Contact Information
As the CSA please provide your contact information:
First Name________________________
Last Name_____________________________________
Phone or email__________________________________
II. Date Crime Occurred (MM/DD/YYYY): _________________________
III. Location/Address of Crime: ______________________________________________________________
Please place a check mark next to the crime location classification below that matches where the
incident occurred:
On-Campus Residence Hall
Non-Campus (University leased or controlled off-campus property)
Public Property (within or immediately adjacent to on-campus property)
IV. Type of Incident
Please place a check mark next to the type of incident being reported (see Attachment A for
definitions of crimes):
Domestic Violence
Liquor Law Violation
Drug Violation
Weapons Violation
Motor Vehicle Theft
Aggravated Assault
Statutory Rape
Dating Violence
Please provide a brief description of the incident in the space below to assist us in classifying it:
V. Hate Crimes
Seattle University is also required to collect and disclose statistics for bias-related crimes (i.e., hate crimes) by the
types of bias. Under the Clery Act, a bias is a preformed negative opinion or attitude toward a group of persons
based on their race, gender, religion, disability, sexual orientation, gender identity, ethnicity or national origin. In
addition to the crimes listed above, the following crimes must be reported by a CSA if the victim(s) of the crime
was/were targeted specifically because of a bias against them. (See Attachment A for definitions of crimes.)
Any crime involving bodily injury
Simple Assault
Larceny (theft)
No If yes, how many crime victims?______Was it a Hate Crime? Yes
Category of Bias:
Gender Identity
National Origin
Sexual Orientation
Other ______________
If "yes" is checked above, please provide a brief summary of the evidence supporting bias motivation:
VI. Disciplinary Referrals
Did you refer a person(s) to the University student conduct system for violations of state or local Alcohol, Drug or
Weapon laws? (See Attachment A for definitions.)
Alcohol violations
Drug violations
Weapon violation
If so, how many people did you refer?_______
If so, how many people did you refer?_______
If so, how many people did you refer?_______
Click the button below to submit this form to Public Safety using your preferred email application:
This form can also be emailed to publicsafety@seattleu.edu or submitted in-person at the
Public Safety office in room 102 of the University Services Building.
Submit Form
Below is a list of the incidents that Seattle University is required collect and report and which, you as a CSA, are require
to report to the University once you are made aware of it.
Murder: The willful (non-negligent) killing of a human being by another. Note: Deaths caused by negligence, attempts to
kill, assaults to kill, suicides, accidental deaths, and justifiable homicides are excluded.
Manslaughter: The killing of another person through gross negligence.
Robbery: The taking or attempting to take anything of value from the care, custody, or control of a person by force or
threat of force or violence and/or by putting the victim in fear.
Aggravated Assault: An unlawful attack by one person upon another for the purpose of inflicting severe or aggravated
bodily injury. This type of assault usually is accompanied by the use of a weapon or by means likely to produce death or
great bodily harm. It is not necessary that injury result from an aggravated assault when a gun, knife or other weapon is
used which could or probably would result in a serious potential injury if the crime were successfully completed. An
unlawful assault upon the person of another for the purpose of inflicting severe or aggravated bodily injury. (Includes
attempts, and whether or not an injury occurred.)
Burglary: The unlawful entry of a structure to commit a felony or a theft. For reporting purposes this definition
includes: unlawful entry with intent to commit a larceny or a felony; breaking and entering with intent to commit a
larceny; housebreaking; safecracking; and all attempts to commit any of the aforementioned.
Motor Vehicle Theft: The theft or attempted theft of a motor vehicle. (Classify as motor vehicle theft all cases where
automobiles are taken by persons not having lawful access, even though the vehicles are later abandoned - including joy
Arson: Any willful or malicious burning or attempt to burn, with or without intent to defraud, a dwelling, house, public
building, motor vehicle or aircraft, personal property of another kind.
Sex Offenses: Any sexual act directed against another person, without the consent of the victim, including instances
where the victim is incapable of giving consent. Sex offenses are separated into two categories: forcible and non-forcible.
Forcible Sex Offense: Any sexual act directed against another person, forcibly and /or against that person’s will; or not
forcibly or against the person’s will where the victim is incapable of giving consent. Forcible sex offenses include rape
and fondling:
Rape: The penetration, no matter how slight, of the vagina or anus with any body part or object, or oral penetration by
a sex organ of another person, without the consent of the victim.
Fondling: The touching of the private body parts of another person for the purpose of sexual gratification, forcibly and/
or against the person’s will; or, not forcibly or against the person’s will where the victim is incapable of giving consent
because of his/her age or because of his/her temporary or permanent mental incapacity.
Non-Forcible Sex Offenses: Unlawful, non-forcible sexual intercourse. Non-forcible sex offenses include incest and
statutory rape:
Incest: Non-forcible sexual intercourse between persons who are related to each other within the degrees wherein
marriage is prohibited by law.
Statutory Rape: Non-forcible sexual intercourse with a person who is under the statutory age of consent.
Dating Violence: Violence committed by a person who is or has been in a social relationship of a romantic or
intimate nature with the victim. The existence of such a relationship shall be determined based on the reporting
party’s statement and with consideration of the length of the relationship, the type of relationship, and the frequency
of interaction between the persons involved in the relationship. For the purposes of this definition—
(1) Dating violence includes, but is not limited to, sexual or physical abuse or the threat of such abuse.
(2) Dating violence does not include acts covered under the definition of domestic violence.
Domestic Violence: A felony or misdemeanor crime of violence committed
(1) By a current or former spouse or intimate partner of the victim;
(2) By a person with whom the victim shares a child in common;
(3) By a person who is cohabitating with or has cohabitated with the victim as a spouse or intimate partner;
(4) By a person similarly situated to a spouse or the victim under the domestic or family violence laws of the
jurisdiction in which the crime of violence occurred, or
(5) By any other person against an adult or youth victim who is protected from that person's acts under the
domestic or family violence laws or the jurisdiction in which the crime of violence occurred.
Stalking: Engaging in a course of conduct directed at a specific person that would cause a reasonable person to
(1) Fear for the person's safety or the safety of others; or
(2) Suffer substantial emotional distress.
(3) For the purposes of this definition, "course of conduct" means two or more acts, including, but not limited to,
acts in which the stalker directly, indirectly, or through third parties, by any action, method, device, or means
follows, monitors, observes, surveils, threatens, or communicates to or about, a person, or interferes with a
person's property. "Reasonable person" means a reasonable person under similar circumstances and with similar
identities to the victim. "Substantial emotional distress" means significant mental suffering or anguish that may,
but does not necessarily, require medical or other professional treatment or counseling.
Hate Crimes
Seattle University is also required to report statistics for bias-related crimes (i.e., hate crimes) by the types of bias
defined below for the following classifications: murder, manslaughter, sex offenses (forcible and non-forcible), robbery,
aggravated assault, burglary, motor vehicle theft, and arson (see definitions above), as well as larceny-theft, destruction/
damage/vandalism of property, intimidation, and simple assault (see definitions below):
Larceny-Theft (Except Motor Vehicle Theft): The unlawful taking, carrying, leading, or riding away of property from the
possession or constructive possession of another. Attempted larcenies are included. Embezzlement, confidence games,
forgery, worthless checks, etc., are excluded.
Destruction/Damage/Vandalism of Property: To willfully or maliciously destroy, damage, deface, or otherwise injure
real of personal property without the consent of the owner or the person having custody or control of it.
Intimidation: To unlawfully place another person in reasonable fear of bodily harm through the use of threatening
words and/or other conduct, but without displaying a weapon or subjecting the victim to actual physical attack.
Simple Assault: An unlawful physical attack by one person upon another where neither the offender displays a weapon,
nor the victim suffers obvious severe or aggravated bodily injury involving apparent broken bones, loss of teeth, possible
internal injury, severe laceration, or loss of consciousness.
If a hate crime occurs where there is an incident involving intimidation, vandalism, larceny, simple assault or other bodily
injury, the law requires that the statistic be reported as a hate crime even though there is no requirement to report the
crime classification in any other area of the form.
Under the Clery Act, a Hate Crime is a criminal offense that manifests evidence that the victim was intentionally
selected because of the perpetrator’s bias against the victim. Although there are many possible categories of bias,
under the Clery Act, only the following eight categories are reported: race, religion, sexual orientation, gender, gender
identity, ethnicity, national origin, and disability.
Alcohol, Drug, or Weapon Law Violations
Drug/Narcotic Violations: The violation of laws prohibiting the production, distribution and/or use of certain
controlled substances and the equipment or devices utilized in their preparation and/or use. The unlawful cultivation,
manufacture, distribution, sale, purchase, use, possession, transportation or importation of any controlled drug or
narcotic substance. Arrests for violations of state and local laws, specifically those relating to the unlawful possession,
sale, use, growing, manufacturing and making of narcotic drugs. The relevant substances include opium or cocaine and
their derivatives (morphine, heroin, codeine); marijuana; synthetic narcotics—manufactured narcotics that can cause
true addiction (Demerol, methadone); and dangerous non-narcotic drugs (barbiturates, Benzedrine).
Alcohol Violations: The violation of state or local laws or ordinances prohibiting the manufacture, sale, purchase,
transportation, possession or use of alcoholic beverages, not including driving under the influence and drunkenness.
Weapons Violation: The violation of laws or ordinances prohibiting the manufacture, sale, purchase, transportation,
possession, concealment, or use of firearms, cutting instruments, explosives, incendiary devices or other deadly
weapons. This classification encompasses weapons offenses that are regulatory in nature.