Date incident reported to CSA*
CSA Contact Information*
Date incident occurred*
Location classification (select one)*

When in doubt if an incident occurred on a Clery defined property, CSA’s should still submit this completed form. A determination will be made by the UT Police Department if the location is on Clery defined property.

Victim/Suspect Relationship*
Was this incident motivated by bias?
To your knowledge, was this incident reported to an agency?

For tracking purposes and to avoid double counting incidents, please include a victim personal identifier such as the initials of their first, middle and last name if available. This information will not be published in Safety Notices or Crime Statistics.

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