Campus Security Authority Clery Incident Reporting form

Information requested in this form is necessary to compile campus crime statistics in accordance with federal law.

This form should be completed by those individuals identified as a “Campus Security Authority” who are required to report information they receive about specific crimes, described below, pursuant to the federal Clery Act.

The information collected from this process will be used to prepare a compilation of statistical crime data which will be included in the Annual Security Report pursuant to the federal Clery Act.

It is the policy of Arizona State University to ensure that victims and witnesses to crime are aware of their right to report criminal acts to the police and to report university policy violations to the appropriate office; e.g., student conduct violations to the student judicial or conduct office on their campus. However, if a reporting person requests anonymity, this request will 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 or her consent. The Clery Act Compliance Coordinator will use this form to determine the category of crime and location under which the crime should be reported as defined by the requirements of the Clery Act.

For incidents requiring an immediate response, email the ASU Police Department, or call 480-965-3456.

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First and last name required
Name of Enforcement Agency to which the incident was reported
Corresponding case number from Enforcement Agency
If reported by a third-party, please note the relationship to the victim.
Was the crime reported to ASU Police?
Was the crime reported to another law enforcement agency?
Does the victim want the incident reported to law enforcement?