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Darton State College Department of Public Safety | Campus Security Authority Crime & Incident Report Form

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Campus Security Authority Crime & Incident Report Form

Please use this form if you are an individual identified as a “Campus Security Authority” to report the required information about specified crimes (listed below) pursuant to the Federal Clery Act. The information collected from these forms is used to prepare a compilation of statistical crime information for inclusion in the campus’ Annual Security Report.

Click here for the PDF version of the form.

CSA Contact Information:
Yes
No

Incident Information:
To the best of your knowledge, what crime are you reporting:

Please Refer to the Crime Definitions document for assistance


For the following crimes, please indicate how
many persons arrested/referred for each category

Please indicate if the same person was arrested/referred for multiple crimes.


Describe the incident in detail. This will be used to aide in determining the proper Clery classification and to aide in identifying duplicate reporting.

Yes   No   Unknown

Location Information:
Check appropriate location:

Specific Building, address, or name of streets, city

Resident hall room, office, or street.


Hate Crime Information

Hate Crime information must be reported for each of the following crimes: criminal homicide, sex offenses, robbery, aggravated assault, simple assault, burglary, larceny theft, motor vehicle theft, vandalism, intimidation and arson and for any other crime involving bodily injury.

Check type of prejudice:

Yes   No

It is the policy of Darton State College and University System of Georgia Board of Regents, to ensure that the victims and witnesses to crime are aware of their right to report criminal acts to the police and to report Darton State College policy violations to the appropriate office (e.g. student conduct violations to the V.P. Student Affairs). However, if a reporting person requests anonymity, this request must be honored to the extent permitted by law. Accordingly, no information should be included on this form that would personally identify the victim without his/her consent.

Based on information received, Darton State College Police will determine the category of the crime or incident and the location under which the incident should be reported in the Annual Security Report.

The legislation requires that each department’s records related to the Clery reportable crime statistics be retained for seven years.

For questions regarding this form and for Divisions that report a large number of alcohol related incidents, please contact Chief James Brackin at james.brackin@darton.edu or 229-317-6315 to discuss approaches for more efficient provision of the information.

Responsible Department: Public Safety
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