CSA Crime Statistics Reporting Data Form

This form is solely for the purpose of collecting data for statistical reporting required by the Crime Awareness and Campus Security Act, as amended by the Higher Education Amendments of 1998.

Please fill out the secure web-based form below. You also have the option to print the crime reporting form and submit this form in person at the Division of Public Safety, 4040 Chestnut Street, send via email to , or via fax to 215-573-7042.

You may contact Penn Police at any time by visiting department headquarters at 4040 Chestnut Street, calling 215-573-3333 or 511 from any campus phone, or by using one of the many Bluelight and emergency telephones located throughout the campus.

For more on Clery reporting visit www.publicsafety.upenn.edu/clery or call Penn’s Division of Public Safety’s Special Services Department at 215-898-4481 (898-6600 off-hours).

This form is to be completed by University officials with significant responsibility for student and campus activities.

Name of Person Completing Form
Title of Person Completing Form
Department/Office
Phone Number
Email*
Signature

Verify By Typing Your Name Here
Date
MM slash DD slash YYYY
Name of Person to Whom Incident Was Reported
Title of Person to Whom Incident Was Reported
Date Incident Occured
MM slash DD slash YYYY
Time Incident Occured
Date Incident was Reported
MM slash DD slash YYYY
Time Incident Was Reported
Location of Incident

(Name of building, if applicable, street address and room number. NOTE: Room/apartment number may be omitted when the incident reported is of a sensitive nature, and providing this information would jeopardize confidentiality.)
Description of Incident
(Do not include information that may reveal identities of involved parties.)
Please Answer the Following Questions About the Incident
Was A Weapon Involved?
- Yes
- No
- Not Sure
If so, please specify type
Is there evidence that the offense was motivated by bias?
- Yes
- No
If so, please explain in detail the type and nature of the bias.
Victim/Survivor Affiliation

(e.g., faculty, staff, student, visitor, alumni, etc.)
Alleged Offender Affiliation

(e.g., faculty, staff, student, visitor, alumni, etc.)
Resolution of Incident/Action Taken (If Any)
Has this incident been reported to any law enforcement official?
- Yes
- No
If Yes, to whom and When?
Additional Comments

Please Answer the Following Questions About the Incident

215.573.3333

215.898.7297

511

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