CLERY CRIME REPORTING FORM

Form Prepared By:
Name Name First Last
Title
Date Date / MM / DD YYYY
Was this crime reported to any Law Enforcement Agency?

Was this crime reported to any Law Enforcement Agency? Yes No
If “Yes,” to which agency:

If “Yes,” to which agency: SUNY Plattsburgh University Police Department Plattsburgh Police Department Other Other
Was this crime reported to any other Campus Officials?

Was this crime reported to any other Campus Officials? Yes No
If "Yes", to whom was it reported?
Date Reported Date Reported / MM / DD YYYY
Does the reporting individual wish to file a police complaint?

Does the reporting individual wish to file a police complaint? Yes No
Reporting Individual Name Reporting Individual Name First Last
Affiliation with campus
Reporting Individual Address Reporting Individual Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone number Phone number - ### - ### ####
Accused Name
Accused Contact Information if Known: Accused Contact Information if Known:
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone number Phone number - ### - ### ####
Affiliation with campus
The following crime was reported (check all that applies)

The following crime was reported (check all that applies) Robbery Aggravated Assault Burglary Motor Vehicle Theft Arson Negligent Manslaughter Dating Violence Domestic Violence Stalking Illegal Weapons Possession Sex Offense Drug Law Violations Liquor Law Violations Murder (including Non-negligent Manslaughter)
Indicate type of sex offense

Indicate type of sex offense Rape Fondling Incest Statutory Rape
Definitions for each of the above crimes as well as the definition of a hate crime can be accessed here
Was the crime indicated above a hate crime?

Was the crime indicated above a hate crime? Yes No
If Yes, please indicate category

If Yes, please indicate category Race Religion Sexual Orientation Gender Gender Identity Disability Ethnicity National Origin
Was there evidence of a hate crime and did the incident involve simple assault, intimidation, larceny-theft of property OR destruction/damage/vandalism of property?

Was there evidence of a hate crime and did the incident involve simple assault, intimidation, larceny-theft of property OR destruction/damage/vandalism of property? Yes No
If “Yes,” give a brief explanation:
Crime occurred:
Date Date / MM / DD YYYY
Time Time : HH MM AM/PM
Location of Crime:

Location of Crime: On-campus Facility Non-campus Facility Owned/Controlled by SUNY or an Officially Recognized Student Group of SUNY Plattsburgh Public Property Within or Immediately Adjacent to SUNY Plattsburgh
On-campus Location
Specific Address Specific Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Reference the Clery Act Disclosure Locations/Addresses Listing for an up-to-date listing of on- and off-campus, public, and private property locations for which incidents/crimes must be reported. These documents can be accessed here.
Describe the incident:

CLERY CRIME REPORTING FORM

CLERY CRIME REPORTING FORM

Form Prepared By:

Definitions for each of the above crimes as well as the definition of a hate crime can be accessed here

Crime occurred:

Reference the Clery Act Disclosure Locations/Addresses Listing for an up-to-date listing of on- and off-campus, public, and private property locations for which incidents/crimes must be reported. These documents can be accessed here.