Clery Act Incident Report Form

* = Required Fields

Name*
Phone*	() - ext.
Email*
Send me a copy of this submission.	Yes No
Your department
Your position
Date of incident*
Time of incident*	01 02 03 04 05 06 07 08 09 10 11 12 : 00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 AM PM
Description of Incident*	Please provide as much information regarding the incident as you know. DO NOT IDENTIFY THE VICTIM!
Please select the category that best fits the description of the incident you are reporting (check all that apply).* Murder/Non-Negligent Manslaughter - The willful (non-negligent) killing of one human being by another. Manslaughter by Negligence - The killing of another person through gross negligence. Aggravated Assault - An unlawful attack upon another to inflict severe or aggravated bodily injury. This type of assault is usually accompanied by the use of a weapon or means likely to produce death or serious bodily harm. Sexual Assault (Sex Offenses) - Any sexual act directed against another person, without the consent of the victim, including instances where the victim is incapable of giving consent. Please indicate category: Rape, Fondling, Statutory Rape, and Incest. Burglary - Unlawful entry into a structure to commit a felony or theft. Robbery - Taking or attempting to take something by force, violence, threat, or by putting the victim in fear. Motor Vehicle Theft - Theft of automobiles, trucks, etc., including joyriding (taking by a person without lawful access). Arson - Willful or malicious burning or attempt to burn structure, vehicle, or personal property of another. Liquor, Drug, and Weapon Law Violations 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. Stalking - Engaging in a course of conduct directed at a specific person would cause a reasonable person to fear for the person's safety, or would cause substantial emotional distress. Other
Other Category	Please provide details.
Who REPORTED the incident?*	Victim Third-Party Offender
WHERE did the incident occur?*	On-Campus Off-Campus Unknown
If the specific location (building name, street address, etc.) of the incident is known, please list it here.
Is there evidence the incident was motivated by hate or bias?*	Yes No
Identify the potential category of prejudice. (Check all that apply.) Race Gender Gender Identity Religion Sexual Orientation Ethnicity National Origin Disability Not Applicable
Please provide a brief summary of evidence supporting a hate motivation for this event:
Was the incident reported to UMMC PD or another source at UMMC?*	UMMC Police Another UMMC Source No Unknown