CSA Name/Dept./

Print NamePrint Dept.

“CampusSecurityAuthority"EasyCheckOffListforCrimeReportPreparation

AccordingtotheHigherEducationAct,or20U.S.C.1092,nowknownastheJeanneCleryDisclosureofCampusSecurityPolicyandCampusCrimeStatisticsAct,theUniversity of Hawai`i at Hilomustcollectcertaincampuscrimestatistics. All designated Campus Security Authorities (CSAs) are also required to file statements of no crimes reported during any respective calendar year.

If no crimes were reported to you in 2017, please check the box below and sign your name. Federal law requires written documentation that NO crimes were reported to you during the previous calendar year.

By placing an X in this box, you are certifying that no crimes, as listed below, were reported to you during the requested calendar year.

Signature:Date:

Please refer to URL more detailed descriptions of crimes.

Use this sheet to record details/facts ofanincident beingreported to youwhen thevictim doesnot wishtoreport theincidenttoCampus Security or HPD. TheobjectofthisformandyourresponsibilityaretoensureUHHiloisrecordingtheactualnumberofalleged crimesthatoccuronornearthe Universitythroughouttheyear. Pleaseadvisethevictimofacrimethattheirnamewillnotbereported,butFederallawrequiresthecrimeitselfbereported.

Datereported:Date/time of crime:Location:

Use aUHHcampus mapandcirclelocationifnecessary.

Crime:
Murder / Motor vehicle theft / Hate Crime: / Sex Offense:
Manslaughter / Arson / Larceny / Rape
Arson / Drug Violation / Intimidation / Fondling
Burglary / Liquor Law Violation / Simple Assault / Sodomy
Robbery / Weapon Violation / Vandalism / Incest
Aggravated Assault / Terroristic Threat / Assault w/object

(Note: Any rape that is “forcible” is categorized as “rape.” Statutory rape depends on age victim and suspect. If you need assistance with any classification, contact Campus Security at 974-7911.)

LawEnforcementAgency(s)theincidenthasbeenreportedto:
NoneHPDHI State SheriffOther (specify)
Law Agency Report Number:

Pleasegiveadescriptionofthecrime/incidenttohelpCampusSecurityclassifyit:

Check appropriate box if a Hate Crime:

Race / Gender / Religion / Sexual Orientation / Ethnicity / Disability

Additional Information:

Date Submitted:Phone:E-mail:

Pleasesubmitthis formtoUH Hilo Campus Security(UCB, 301-151) andkeepacopyforyourrecords.Ifyouhavequestionsaboutclassifyingacrimeor alocation,contactany Security Supervisor974-7911,or .