Clery Act Incident Report Form

* = Required Fields

Name*	*
Phone*	() - ext.******
Email*	*Invalid Email
Send me a copy of this submission.	Yes No
Your department
Your position
Date of incident*	*Invalid Date
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 *