University Police

Clery Report Form

NOTE: If you need IMMEDIATE ASSISTANCE call the University Police directly at 911 from any campus phone or (518) 442-3131. This form generates a report that is normally reviewed during business hours and should not be used if you need an immediate response.


The form below is intended for the sole use of those persons designated as Campus Security Authorities [CSA] at and for the University at Albany as required under the Jeanne Clery Disclosure of Campus Security Policy and Campus Crime Statistics Act, [Clery Act] codified at 20 USC 1092 (f) as a part of the Higher Education Act of 1965. All reports made through this form will be confirmed by contacting the CSA reporting the incident.

This form is to be used when a CSA has received information regarding an incident that they, in good faith, believe to be a reportable offense under the Clery Act and where the victim does not wish to report the incident to the police. Please fill in all of the fields below. Please be as complete as possible to provide the University with the best opportunity to respond to this incident.

Information on the reporting requirements may be found in the Handbook for Campus Crime Reporting. Information specific to the duties of Campus Security Authorities may be found in chapter 4 of the Handbook.

In all cases the person reporting the incident to the Campus Security Authority may choose to withhold their identity.


Do you know what offense may have been committed?

See the Handbook for Campus Crime Reporting for a full description of these offense categories - starting on page 23. Remember you are documenting your good faith estimate of what offense was reported to you. Law enforcement representatives will review the information given and make an official determination as to whether the elements of a particular offense are present. As always, "when in doubt report it out".)


What type of crime or incident has occurred or is going to occur?


Enter the date of the incident:

(mm/dd/yyyy)

Enter the time of incident:

(hh:mm am/pm)


General Location of Incident

(The basic definitions of the locations may be found below)

In Residence Hall

Yes   No Unknown
"In Residence Hall" is a sub-set of the "On Campus" category (below). If an incident is reported as having occurred within a residence hall note it in the "In Residence Hall" location rather than in the "On Campus" category below.

On Campus

Yes   No Unknown

Any building or property owned or controlled by an institution within the same reasonably contiguous geographic area and used by the institution in direct support of, or in a manner related to, the institution's educational purposes, including residence halls; and Any building or property that is within or reasonably contiguous to paragraph (1) of this definition, that is owned by the institution but controlled by another person, is frequently used by students, and supports institutional purposes (such as a food or other retail vendor).

Non-Campus

Yes   No Unknown

Any building or property owned or controlled by a student organization that is officially recognized by the institution; or Any building or property owned or controlled by an institution that is used in direct support of, or in relation to, the institution's educational purposes, is frequently used by students, and is not within the same reasonably contiguous geographic area of the institution.
 

Public Property

Yes   No Unknown

All public property, including thoroughfares, streets, sidewalks, and parking facilities, that is within the campus, or immediately adjacent to and accessible from the campus.


Describe what was reported to you

  • What occurred,

  • Were there any injuries,

  • Specific location (name of the residential hall, podium building, etc.),

  • Were police/campus officials involved,

  • Etc.

  • DO NOT include identifying information (name, room number, etc.) unless the victim requests that you do so.


Was this incident Hate or Bias related?
(If yes please indicate type of bias):

(See the Handbook for Campus Crime Reporting for more information on Hate Crimes reporting requirements under the Act.)

Yes No Unknown


Race
Gender
Religion
Sexual orientation
 

Ethnicity
Disability
Gender Identity
National Origin
Other

 


Please give us any other information that you feel is pertinent
(past incidents, other actions taken on your part to assist the victim, etc..)


THE INFORMATION BELOW IS MANDATORY

 

Date Reported to CSA:

Time Reported to CSA:

Name of Reporting CSA:

Street Address:

Address (cont.):

City:

State/Province:

Zip/Postal Code:

Work Phone:

E-mail


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