Printable Form Print Incident Report Form

The Campus Security Authority (CSA) is to document as much of the requested information on the form, excluding identity if confidentiality is requested, as s/he knows. The awareness can come from a direct report from a student or staff member or from a third party. University Police will use the submitted information to verify the appropriate classification of the crime.

The University has made many resources available to victims/witnesses of crime at no cost. If you would like to learn more about these resources, have any questions, or would like assistance completing this form please contact: Tracie Bogus; (814) 863-1273 or tib2@psu.edu.

Note: Please complete all relevant fields. Required fields are marked in bold red with an asterisk (*)
Select the campus where the incident occurred.
mm/dd/yy
CSA Contact Information
999-999-9999
A valid phone number OR email address is required.
Incident Details
OR
Enter the date range of the incident(s) you are reporting (mm/dd/yy TO mm/dd/yy).
OR
Check here if the date the incident occurred is unknown.

Please provide specific, detailed information related to the reported incident(s).

(select all that apply)
Homicide - Murder
Non-negligent manslaughter; and negligent manslaughter (including vehicular manslaughter).
Aggravated Assault
Unlawful attack upon another with intent to inflict severe injury or great bodily harm.
Sex Offense
Rape (including sodomy or sexual assualt with object)
Fondling
If rape or fondling, were the victim and the offender acquainted (did they know each other)? Yes No Unknown
Statuatory Rape (victim under the legal age of consent)
Incest
Burglary
Unlawful entry into a structure to commit a felony or theft
Robbery
Taking or attempting to take something by force; violence; threat; or by putting victim in fear
Motor Vehicle Theft
Theft of automobiles; trucks; etc.; including "joyriding" (taking by person without lawful access)
Arson
Willful or malicious burning / attempt to burn structure; vehicle; or personal property of another
Dating Violence
Violence committed by a person (A) who is or has been in a social relationship of a romantic or intimate nature with the victim; and (B) where the existence of such a relationship shall be determined based on a consideration of the following factors:
(i) The length of the relationship;
(ii) The type of relationship;
(iii) The frequency of interaction between the persons involved in the relationship. Dating violence includes threats of, or use of,
physical, sexual, verbal, emotional, economic or psychological action to influence or control the victim.
Domestic Violence
Felony or misdemeanor crimes of violence committed by a current or former spouse or intimate partner of the victim, by a person with whom the victim shares a child in common, by a person who is cohabitating with or has cohabitated with the victim as a spouse or intimate partner, by a person similarly situated to a spouse of the victim under the domestic or family violence laws of the jurisdiction receiving grant monies, or by any other person against an adult or youth victim who is protected from that person's acts under the domestic or family violence laws of the jurisdiction.
Stalking
Engaging in a course of conduct directed at a specific person that would cause a reasonable person to fear for his or her safety or the safety of others, or suffer substantial emotional distress.
Liquor (A) Drug (B) and/or Weapon Law (C) Violation
If the incident was a liquor, drug or weapon law violation, please indicate if the incident involved an arrest (any individual) or if the violation resulted in a student disciplinary referral instead of an arrest:
(A) Liquor Underage possession or consumption; distribution to minors
Arrest Disciplinary Referral
(B) Drug Use; possession or distribution of controlled substances or possession of drug paraphernalia
Arrest Disciplinary Referral
(C) Weapon Law Possession or use of an illegal weapon
Arrest Disciplinary Referral
If crime not listed above, please enter new crime category.

If, to your knowledge, a law enforcement agency was notified, please enter the name of that agency.


Was the crime reported to you by the victim, a third party, or both? If so, choose one or both.
Third Party Victim
If a third party reported the crime to you, please enter the relationship of the third party to the victim.
Do not enter if confidentiality is requested.
Do not enter if confidentiality is requested.

What best describes the location of the crime? If the crime occurred in multiple places, check all that apply:
On campus, residence hall
Public property immediately adjacent to campus (sidewalks, streets, etc.)
On campus, not in a residence hall
Non-Campus in University owned leased or controlled space (fraternity/sorority)
Unknown location, other
If known, provide specific occurrence location (building name, street address, office number, etc.).

Is there evidence that this crime was motivated by bias? Yes No
If you answered "Yes" to the Motivated by Bias question, please choose any/all potential categories of prejudice.
Race
Religion
National Origin
Ethnicity
Disablity
Sexual Orientation
Gender
Gender Identity

If you answered "Yes" to the Motivated by Bias question, please provide a brief summary of the evidence supporting a bias motivation.

Once completed, you may submit this form electronically by clicking on the Submit button below or print the form and send to:

University Police and Public Safety
The Pennsylvania State University
Attn: Compliance Coordinator
30 Eisenhower Parking Deck
University Park, PA 16802

* Please enter the characters from the above image (case sensitive):