CSA Crime Statistic Report Form

If no crimes were reported to you this year, check the box below, enter your name and phone number. This form is being used to document that you have received this reporting form and that no crimes were reported to you for the previous reporting cycle.*

No crimes were reported to me this year
Yes, crime(s) were reported to me this year

Reporting Person*

First Last

Email*

Phone Number*

Complete this box if a crime was reported to you. If more than one crime was reported to you, fill out one of these forms for each crime reported.

The Jeanne Clery Disclosure of Campus Security Policy and Campus Crime Statistics Act (“Clery Act”) found in 20 U.S.C.§1092(f) requires the University to compile and report information on certain crimes, including certain types of sexual violence/assault. As noted by this law, all Universities receiving federal financial aid must report the statistical information on crimes that occur on campus and include them in an annual report.The statistical information collected for this report will not contain any names or specific locations (e.g..room numbers) to maintain the confidentiality of a victim.

Online CSA Training
Click here to get to the original website (slides 1-15 only)

Please visit the Title IX Policies and Procedures website in regards to the obligations for responsible employees at Missouri Western State University.

Please review the Background on Statistical Reporting Requirements Under the Clery Act for any question on crime classifications.

Crime Classification*

Location of Incident (building name or address)*

Date Incident Reported (mm/dd/yyyy)*

Time Incident Reported*

: HH

MM

Date Incident Occured (mm/dd/yyyy)

Time Incident Occured

: HH

MM

Brief description of the incident

Did the crime occur in a building?*

Did the crime occur on (Institution) owned, controlled, or leased property?*

Did the crime occur at a University-sponsored activity or event?*

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