UIC Campus Security Authority Reporting Form

CLERY INCIDENT REPORTING FORM
for UIC mandatory crime reporters (Campus Security Authorities)

EMERGENCIES: If this is a serious crime or incident that may cause an imminent or ongoing threat to the campus community, contact the University of Illinois at Chicago (UIC) Police Department (UICPD) at (312) 355-5555 or 5-5555 from a campus phone or your local law enforcement agency by dialing 911.

UIC Campus Security Authorities (CSAs) are instructed to forward certain information to UIC Police when they learn of Clery-reportable crimes that occur on UIC Clery geography. This form should be submitted in a timely manner whenever a CSA is made aware of a potential Clery-qualifying incident. The information shared through this form allows the university to:

Assess whether a Public Safety Advisory email is warranted to warn the campus community of a serious or ongoing threat (i.e., a timely warning notice)
Maintain an up-to-date Daily Crime Log
Disclose Clery-qualifying crime statistics in the UIC Annual Security and Fire Safety Report.
Connect reporting persons (or others involved) to additional resources, when feasible and appropriate.

Submissions of this form are received and reviewed by the UIC Police Department Crime Statistics Unit, and submissions indicating sexual misconduct are also received and reviewed by a UIC Title IX Coordinator. Completion of this electronic form does not replace the filing of a formal complaint (with the UICPD, or your local law enforcement agency). To file a formal complaint, law enforcement must be contacted directly.

Download or bookmark the Clery CSA Reporting Guide to review CSA reporting obligations: go.uic.edu/CSACheatSheet

CAMPUS SECURITY AUTHORITY INFORMATION

Campus Security Authority (CSA) contact information:
*CSA contact information is mandatory, as we may need to follow-up with you.

First Name:*

Last Name:*

Phone Number: *

UIC E-mail Address:*

Did you (the CSA) witness the incident, or did someone else report the incident to you?

I (the CSA) witnessed the incident.
Someone else reported this incident to me.

Please read to the reporting person, prior to completing the CSA Incident Reporting Form (when possible):
"As part of my position at UIC, I am required to report certain information about this incident to UIC Police. The information I report helps the university to track crimes that might affect the campus and to provide timely warnings if there is a serious or ongoing threat to the campus community. If you request anonymity, identifying information may be excluded from the report (such as your name and contact information)- I’ll only report the information you provide. However, if the incident involves sexual harassment or misconduct, identifying information of the persons involved must be reported to UIC’s Title IX Coordinator. Do you have any questions? Would you like to help me fill out the form?"

REPORTING PARTY INFORMATION

The "reporting party" is the person who made the incident known to the Campus Security Authority (CSA). The reporting party could be a victim, witness, or another third party.

Who reported the crime to the CSA?
If the reporting party does not want to be identified, select "Reporting Party would like to Remain Anonymous," otherwise, the reporting party's contact information will be requested and may be used for follow up.

Victim

Witness

Other Third Party

Reporting Party Wishes to Remain Anonymous

What is the third party reporter's relation to the incident?
Examples: Friend of the victim, overheard a conversation, etc.

Provide the reporting party's contact information:

First Name:

Last Name:

Phone Number:

UIC E-mail Address:

If the reporting party wishes to report anonymously, please enter only the first and last initials of the reporting party. This will help us make comparisons to avoid double reporting.
Example: Enter reporting party "John Smith" as "JS"

Date incident was reported to CSA:
Enter the date the incident was reported to you.

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Time incident was reported to CSA:
Enter the approximate time the incident was reported to you, including AM or PM.

INCIDENT DATE & TIME

Date incident occurred:
Select the date (or approximate date) the incident occurred.

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Time incident occurred:

Enter the approximatet time the incident occurred, including AM or PM.

INCIDENT LOCATION

UIC Campus associated with the incident
Select the campus on/near which the incident occurred

Chicago Campus East

Quad Cities Campus

Chicago Campus West

Rockford Campus

UIC School of Law

Springfield Campus

Peoria Campus

Urbana Campus

Select the geography category that most closely describes where the incident occurred

UIC On-campus Property
Building or property owned or controlled by UIC or owned by UIC but controlled by another person, is frequently used by students, and supports institutional purposes.
Examples: Student Centers East; School of Public Health & Psychiatric Institute; Halsted St. Parking Structure; Curtis Granderson Stadium; Rockford COM East East Building; College of Medicine Peoria.

Public Property
Thoroughfares, streets, sidewalks, and parking facilities, that is within the campus or immediately adjacent to and accessible from the campus.

UIC Student Housing Facility
Campus Housing
Examples: Courtyard, Commons West, James Stuckel Tower (JST), Marie Robinson Hall (MRH).

Off-campus Building or Property

Building or property not owned or regularly utilized by a recognized student organization or by UIC and not within a one mile contiguous area of the respective campus.

UIC "Noncampus" Property
Off-campus building or property used for UIC activities, such as student organization activities, student training or education, student housing facilities, etc.
Examples: Pharmacognosy Field Station; Mile Square Health Centers; Intercollegiate Athletics travel.

Additional information describing the incident location

Include building name, address, street name with cross streets or close address, or nearby buildings if the incident occurred outside.

Did the off-campus incident occur at a UIC event or in conjunction with a UIC activity?
UIC activities can include university-sponsored travel; registered student organization meetings or events; networking or social events organized by UIC or any of its units; meetings or conferences for university business; etc.

Yes (If yes, explain:)
No

CRIME CLASSIFICATION

CSAs are not expected to be experts crime definitions, but we ask you to please do your best to provide enough detail so UIC Police and the UIC Title IX Coordinator can accurately assess and respond to reports.

Select the crime categories you wish to report:

Sexual Misconduct, Dating/Domestic Violence, Stalking
Another Type of Crime
Student or Employee Alcohol, Drug, or Weapon Law Violations

ATTENTION: UIC SEXUAL MISCONDUCT POLICY & OPTIONS

Regardless of whether a victim elects to pursue a criminal complaint or whether the offense is alleged to have occurred on or off campus, UIC will assist victims of sexual misconduct and will provide each victim with their rights and options. Click the following links to access: Reporting Rights and Options or Survivor Support Resources (including how to get safe and get help, how to preserve evidence, and where to access on- and off-campus survivor advocacy and support).

For more information about UIC's Sexual Misconduct processes, review UIC's Sexual Misconduct Policy and/or contact UIC's Title IX Coordinator at 312-996-8670 or click to e-mail: TitleIX@uic.edu.

To be connected to UIC's confidential, trauma-informed victim advocacy services, contact the Campus Advocacy Network (CAN). Victims have the rights to have an advocate accompany them throughout any processes in which they choose to engage. Click to e-mail a confidential advisor/advocate to discuss your needs and assess your on and off campus options, or call 312-413-8206.

Based on what you witnessed, or what was reported to you, select the category of sexual misconduct that best describes the incident being reported

Select all offenses that apply to the incident being reported.

Dating Violence
Violence committed by a person who is or has been in a social relationship of a romantic or intimate nature with the victim.
(1) 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.
(2) For the purpose of this definition - (i) Dating violence includes, but is not limited to, sexual or physical abuse or the threat of such abuse; or (ii) Dating violence does not include acts covered under the definition of domestic violence.
Domestic Violence
A felony or misdemeanor crime of violence committed - (i) By a current or former spouse or intimate partner of the victim; (ii) By a person with whom the victim shares a child in common; (iii) By a person who is cohabiting with or has cohabited with the victim as a spouse or intimate partner; (iv) By a person similarly situated to a spouse of the victim under the domestic or family violence laws of the jurisdiction in which the crime of violence occurred; or (v) By any other person against an adult or youth victim who is protected from that person's acts under the domestic or family violence laws of the jurisdiction in which the crime of violence occurred.
Stalking
(1) Engaging in a course of conduct directed at a specific person that would cause a reasonable person to - (i) Fear for the person's safety or the safety of others; or (ii) Suffer substantial emotional distress.
(2) For the purpose of this definition - (i) Course of conduct means two or more acts, including, but not limited to, acts in which the stalker directly, indirectly, or through third parties, by any action, method, device, or means follows, monitors, observes, surveils, threatens, or communicates to or about, a person, or interferes with a person's property; (ii) Reasonable person means a reasonable person under similar circumstances and with similar identities to the victim; or (iii) Substantial emotional distress means significant mental suffering or anguish that may, but does not necessarily, require medical or other professional treatment or counseling.
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.
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.
Statutory Rape
Sexual intercourse with a person who is under the statutory age of consent. Illinois statutory rape law is violated when a person has consensual sexual intercourse with an individual under age 17. However, if the offender is in a position of authority or trust over the victim, the age of consent is raised to age 18. Persons age 16 or younger may not legally consent in Illinois. (If force was used or threatened or the victim was incapable of giving consent because of age or temporary or permanent mental impairment, classify as rape, not statutory rape.)
Other sexual misconduct (explain):

Is it believed this incident is a hate crime, or a crime motivated by an offender's bias against the victim?
An incident that manifests evidence that the victim was intentionally selected because of the perpetrator's prejudice against the victim is categorized as a hate crime. The categories of prejudice may include the victim's actual or perceived: race, religion, gender, gender identity, sexual orientation, ethnicity, national origin, and disability.

Yes

No

Select any/all potential categories of prejudice believed to motivate the incident:

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, or whites.

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.
E.g. Lesbian, gay, bisexual, and heterosexual (straight).

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.

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 and/or ideology that stresses common ancestry.
I.e. 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.

Gender
A preformed negative opinion or attitude toward a person or group based on their actual or perceived gender.
E.g. Male or female

National Origin
A preformed negative opinion or attitude toward a group of people based on their actual or perceived country of birth.
I.e. This bias may be against people that have the 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 associated with people of a certain national origin.

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; a gender non-conforming person may not be a lesbian, gay, transgender, or bisexual but may be perceived as such.

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.

Why does the reporting party believe the incident was motivated by bias?

REFERRALS FOR DISCIPLINARY ACTION

A "referral" includes any type of UIC record created in response to a student or employee violating a liquor law, drug law, or weapons law. Include referrals to the Dean of Students, Human Resources, or other disciplinary bodies.

Report the type of violation and number of offenses.

Number of persons referred for Liquor Law Violations:
Number of persons referred for Drug Law Violations:
Number of persons referred for Weapons Law Violations:

INCIDENT DESCRIPTION

Briefly describe the reporting party's account of the incident (what happened?):

Include all relevant information that would help UIC to classify the incident. Try to be as detailed as possible, given what you know.

Number of victims:

Number of offenders:

Provide a brief description of the involved parties:

Include any information about the suspected victim(s) or offender(s), including name(s), clothing, hair/eye/skin color(s), or tattoos.

Note: For anonymous reporting, do not include any information that would jeopardize the anonymity of the reporting party's identity if anonymity has been requested.

AGENCIES NOTIFIED

To your knowledge, has a law enforcement agency been notified of this incident?
Examples: UIC Police, Chicago Police Department, Rockford Police Department, etc.

Yes

No

If a law enforcement agency has been notified, please enter the name of that agency:
Examples: UIC Police, Chicago Police Department, Rockford Police Department, etc.

Does the reporting party want the incident reported to a law enforcement agency for follow up or investigation purposes?

Yes

No

Unknown

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