Campus Security Authority Incident Report Form (Clery Act Reporting)

Who Should Use This Form?

The form below should be used by Campus Security Authorities to report crimes under the Clery Act that they have knowledge of but were not formally reported or investigated by the Police Department. This is an anonymous form that allows the Police Department more accurately track the number of crimes that are actually occurring for Clery reporting purposes. It is important to the members of NC State University Police Department that the crime statistic information that it provides to the public is as clear and as accurate as it possibly can be. 

The following crimes should be reported using this form:

  • Murder/Non-Negligent Manslaughter – The willful killing of one human being by another.
  • Negligent Manslaughter – The killing of another person through gross negligence.
  • Forcible Sex Offense – Any sexual act directed against another person forcibly and/or against that person’s will; or not forcibly or against the person’s will where the victim is incapable of giving consent.
  • Non-Forcible Sex Offense – Unlawful, non-forcible sexual intercourse.
  • Robbery – Taking or attempting to take anything of value from the care, custody or control of a person or persons by force or threat of violence and/or by putting the victim in fear.
  • Aggravated Assault – Unlawful attack by one person upon another for the purpose of inflicting severe or aggravated bodily injury. Usually accompanied by the use of a weapon or by means likely to produce death or great bodily harm.
  • Burglary – Unlawful entry of a structure to commit a felony or a theft.
  • Motor Vehicle Theft – The theft or attempted theft of a motor vehicle. There are three classes of motor vehicle (1) autos, (2) trucks and buses, (3) and other vehicles.
  • Arson – Willful or malicious burning or attempt to burn with or without intent to defraud a dwelling house, public building, motor vehicle or aircraft, or the personal property of another.
  • Relationship/Dating Violence - Conduct arising out of a personal, intimate relationship that: (a) Inflicts physical injury upon another person; or (b) Places another in fear of, or at risk of, physical injury or danger.
  • Stalking:
    • (a) Engaging in a course of conduct directed at a specific person without the legal purpose and the individual engaging in that conduct knows or should know that the course of conduct would case a person to:
      • (i) Fear for the persons safety or the safety of the person's immediate family or close friends; or
      • (ii) Suffer substantial emotional distress.
  • Hate Crime – Any of the above offenses (in addition to damage to property, larceny, simple assault, and intimidation) that manifest evidence that the victim was intentionally selected because of the perpetrator’s bias or perpetrator perceived the person to be in one of the protected group categories.

Date Incident Occurred * :
Date Incident Reported * :
Location of Incident * :
(Check One)
On Campus (Residence Hall)
On Campus (Other than Residence Hall)
Non-Campus Property (owned, controlled, or affiliated with campus; e.g., leased property, fraternities)
Public Property immediately adjacent to campus (sidewalk, street, sidewalk which are adjacent to campus)
Off Campus, Not affiliated or adjacent to campus (e.g., City of Raleigh)
Unknown
Type of Incident:
Murder or Non-Negligent Manslaughter
Forcible Sex Offense
Robbery
Burglary
Arson
Negligent Manslaughter
Non-Forcible Sex Offense
Aggravated Assault
Motor Vehicle Theft
Relationship/Dating Violence
Stalking
Hate Crime (see below)
Briefly Describe the Incident * :
Hate Crimes:
Hate crime information is required to be reported for each of the following crimes:
Murder or Non-Negligent Manslaughter
Forcible Sex Offense
Robbery
Burglary
Arson
Simple Assault
Destruction, Damage, or Vandalism of Property
Negligent Manslaughter
Non-Forcible Sex Offense
Aggravated Assault
Motor Vehicle Theft
Larceny-Theft
Intimidation
Any Other Crime Involving Bodily Injury
Person Receiving Report * :
Phone Number * :
Captcha Code

Click the image to see another captcha.
Please type the letters and numbers shown in the image *