Campus Security Authority – Clery Crime Report Form

Campus Security Authorities as identified by the Clery Act are required to report crimes committed on Peru State College Campus. This document will be used to report the crimes to the Campus Security Department to be added to the Campus Crime Report and daily Crime Log.

Peru State College urges all crime victims and witnesses to report criminal acts to Security, and to report all policy violations to the appropriate office. If a serious crime causes an ongoing threat to the Peru State community, CSA’s must immediately contact Security at (402) 872-2411. Security has the responsibility to notify the community about such crimes so protective steps can be taken.

Campus Security Authority Information
Date Reported Date Reported * / MM / DD YYYY
CSA Name CSA Name * First Last
CSA Phone CSA Phone * - ### - ### ####
CSA Email *
Date of Incident Date of Incident * / MM / DD YYYY
Time of Occurrence (as close as possible) *
Reporting Party Information

*Leave blank if reporting party is requesting anonymity.*
Reporting Party Name Reporting Party Name First Last
Reporting Party Phone Reporting Party Phone - ### - ### ####
Reporting Party Email
Reported by *

Reported by Victim Witness Perpetrator Other Other
Incident Information
Location (street address, office number, floor, area, etc.) *
*

On Campus, Residence Hall On Campus, not in a Residence Hall Public property immediately adjacent to campus (sidewalks, streets, alleys) Off campus, not affiliated with and not adjacent to campus Off campus Peru State sponsored event, activity or trip Unknown location Other Other
Incident Description - provide specific information related to the reported incident. *
Select the category that best fits the description of the crime(s) being reported (check all that apply). Note: If you are unsure if a crime occurred or how to classify a crime, Peru State will use the details in this form to evaluate and classify appropriately.

Select the category that best fits the description of the crime(s) being reported (check all that apply). Note: If you are unsure if a crime occurred or how to classify a crime, Peru State will use the details in this form to evaluate and classify appropriately. Murder/Non-negligent Manslaughter: The willful killing of one person by another. Negligent Manslaughter: The killing of a person through gross negligence (including vehicular manslaughter). 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. This offense includes the rape of both males and females. Fondling: The touching of the private body parts of another person for the purpose of sexual gratification, without the consent of the victim, including instances where the victim is incapable of giving consent because of his/her age or because of his/her temporary or permanent mental incapacity. Incest: Sexual intercourse between persons who are related to each other within the degrees wherein marriage is prohibited by law. Statutory Rape: Sexual intercourse with a person who is under the statutory age of consent Robbery: Taking or attempting to take anything of value from the care, custody, or control of a person or persons 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. Burglary: The unlawful entry of a structure to commit a felony or a theft. (Dorm Room, Office, Locked room/building) Vehicle Theft: Stolen car, motorcycle, motorized vehicle, etc. Arson: 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 Liquor Law Violation: Under age possession or consumption, furnishing liquor to minor. Drug Law Violation: Possession or distribution of a controlled substance. Weapon Law Violation: Unlawful use or possession of a weapon.
Hate Crimes: A criminal offense that manifests evidence that the victim was intentionally selected because of the perpetrator’s bias against the victim.
Is there evidence that the crime was motivated by the perpetrator’s bias? *

Is there evidence that the crime was motivated by the perpetrator’s bias? No Yes
Please identify the bias

Please identify the bias Race: A preformed negative attitude toward a group of persons who possess common physical characteristics, e.g., color of skin, eyes, and/or hair; facial features, etc., genetically transmitted by descent and heredity which distinguish them as a distinct division of humankind, e.g., Asians, blacks or African Americans, whites. Religion. A preformed negative opinion or attitude toward a group of persons who share the same religious beliefs regarding the origin and purpose of the universe and the existence or nonexistence of a supreme being, e.g., Catholics, Jews, Protestants, atheists. Sexual Orientation. A preformed negative opinion or attitude toward a group of persons based on their actual or perceived sexual orientation. Sexual Orientation is the term for a person’s physical, romantic, and/or emotional attraction to members of the same and/or opposite sex, including lesbian, gay, bisexual, and heterosexual (straight) individuals. Gender. A preformed negative opinion or attitude toward a person or group of persons based on their actual or perceived gender, e.g., male or female. Gender Identity. A preformed negative opinion or attitude toward a person or group of persons based on their actual or perceived gender identity, e.g., bias against transgender or gender non-conforming individuals. Gender non-conforming describes a person who does not conform to the gender-based expectations of society, e.g., a woman dressed in traditionally male clothing or a man wearing makeup. A gender non-conforming person may or may not be a lesbian, gay, bisexual, or transgender person but may be perceived as such. Ethnicity. A preformed negative opinion or attitude toward a group of people whose members identify with each other, through a common heritage, often consisting of a common language, common culture (often including a shared religion) and/or ideology that stresses common ancestry. The concept of ethnicity differs from the closely related term “race” in that “race” refers to a grouping based mostly upon biological criteria, while “ethnicity” also encompasses additional cultural factors. National Origin. A preformed negative opinion or attitude toward a group of people based on their actual or perceived country of birth. This bias may be against people that have a name or accent associated with a national origin group, participate in certain customs associated with a national origin group, or because they are married to or associate with people of a certain national origin. Disability. A preformed negative opinion or attitude toward a group of persons based on their physical or mental impairments, whether such disability is temporary or permanent, congenital or acquired by heredity, accident, injury, advanced age or illness.
Check all Hate Crime categories that apply.

Check all Hate Crime categories that apply. Larceny-Theft is the unlawful taking, carrying, leading or riding away of property from the possession or constructive possession of another. Simple Assault is 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. Intimidation is 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. Destruction/Damage/Vandalism of Property is to willfully or maliciously destroy, damage, deface, or otherwise injure real or personal property without the consent of the owner or the person having custody or control of it.
Violence Against Women Act.
Did any of the following VAWA crimes occur? *

Did any of the following VAWA crimes occur? No Yes
Check all VAWA crimes that apply.

Check all VAWA crimes that apply. Dating Violence is defined as 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. Dating violence includes, but is not limited to, sexual or physical abuse or the threat of such abuse. Domestic Violence: Violence committed by a current or former spouse or intimate partner of the victim, by a person with whom the victim shares a child in common, by a person who is cohabitating with or has cohabitated with the victim as a spouse or intimate partner, by a person similarly situated to a spouse. Stalking: Engaging in a course of conduct directed at a specific person that would cause a reasonable person to fear for his or her safety or the safety of others, or suffer substantial emotional distress.

Campus Security Authority – Clery Crime Report Form

Campus Security Authority – Clery Crime Report Form

Campus Security Authority Information

Reporting Party Information

Incident Information

Hate Crimes: A criminal offense that manifests evidence that the victim was intentionally selected because of the perpetrator’s bias against the victim.

Violence Against Women Act.