Page1of2
Volunteer State Community College Crime Incident Report Form
This form should be completed by individuals identified as “campus security authorities – CSA’s” who are required to
report information received about crimes pursuant to the federal Clery Act. The information collected from these forms
will be used to prepare statistical crime information that will be included in the campus’ Annual Security Report. It is the
policy of Volunteer State Community College (VSCC) to ensure that victims and witnesses are aware of their right to
report criminal acts to the police and to report College policy violations to the appropriate office (e.g. Title IX violations
to the Office of Human Resources or student conduct violations to the Office of Student Services). VSCC Campus 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. By calling VSCC Campus Police Department, CSA reporting requirement is met and
this form does NOT need to be completed.
If the reporting person is willing to speak directly with police,
contact VSCC Campus Police at (615) 230-3595.
Return the completed form to the VSCC Campus Police Department:
Hand Deliver to: VSCC Campus Police Department, Wood Campus Center, Room 105
Or
Fax to: (615) 230-4810
Section 1 – Campus Security Authority – Please identify yourself and the person reporting this to you.
(Identify Yourself Here) (Identify Person Reporting Here)
Name:
Title:
Dept:
Phone:
Email:
Today’s Date:
Name:
Address:
Phone:
Email:
Victim
Witness
Other (please
explain)
Section 2 – Date and Location of Incident –be as specific as possible.
• If incident occurred inside a building, identify the address, building name, floor and room number.
• If incident occurred outside, describe the nearest street address or intersection, whether on the street, sidewalk, parking lot, or
inside a vehicle. Be as specific as possible, include any nearby landmarks.
Incident Date:
Incident Address:
Building name, floor, room #
Further Description of Location:
Occurred Inside
College Owned,
Controlled, or Leased
Building
Other Building
Occurred Outside
Street
Sidewalk
Parking lot
Vehicle
College Sponsored Event
or Activity
Incident Date and Time or Date Range:
