Clery Incident Report Form


** Indicates a required field

Name of CSA**:
Department**:
Phone #**:
Email Address**:
Individual Reporting Crime to the CSA**: Victim
Witness
Other
Date of Incident**:
/ /
Time of Incident**:
Address of Incident**:
Location of Incident**:
On-Campus (excluding residence halls)
Non-Campus Property (Duke property away from main campus)
On-Campus Residence Halls
Public Property (public streets adjacent to/running through main campus)
Unknown
Other
Police Report Filed?**
Yes
No
Unknown
Date filled:

Type of Incident** (check all that apply)

See definitions for each type here.

Murder Robbery
Manslaughter Weapon Violation
Drug/Narcotic Violations Burglary
Arson Motor Vehicle Theft
Aggraved Assault Sex Offense (Non-forcible)
Sex Offense (Forcible) Alcohol Violation

Hate Crime

A hate crime a criminal offense committed against a person or property which is motivated, in whole or in part, by the offender's bias. Bias is a preformed negative opinion or attitude toward a group of persons based on their race, gender, religion, disability, sexual orientation or ethnicity/national origin.

Type: Bodily Injury
Telephone
Vandalism
Message
Email
Other
Category of Prejudice: Ethnicity
Race
Religion
Sexual Orientation
Disability
National Origin
Gender
Please provide a brief description of the reported crime or incident: