Clery Incident Report

Campus Security Authority Worksheet | Middle Tennessee State University

One of the purposes of the Clery Act is to promote campus safety by encouraging the reporting of crimes and the disclosure of accurate statistical data regarding crimes occurring on campus and within the geographic limits defined within the Clery Act. This report form has been designed as a uniform procedure to aid the Campus Security Authority (CSA), not part of University Police, in documenting the necessary information (the What, When, and Where) of the reportable crimes defined by the Clery Act. Data collected on this form is to be used to increase public safety, not to identify the victim; therefore, no personal identifying information of the victim shall be included on this form.

It is the policy of Middle Tennessee State University to encourage victims and/or witnesses of crimes to report those crimes to University Police. In some instances a victim or witness may feel more comfortable reporting a crime to a designated CSA. For the purposes of Clery, CSAs are required to document reportable crimes and those non-reportable crimes that are hate or bias based which have occurred in the following areas.

  1. On-Campus Property: Any building or property owned, controlled, or leased by the institution within the same reasonably contiguous geographic area and used by the institution in direct support of, or in a manner related to, the institution’s educational purposes, including residence halls; and

    Any building or property that is within or reasonably contiguous to paragraph (1) of this definition, that is owned by the institution but controlled by another person, is frequently used by students, and supports institutional purposes (such as food or other retail vendor).

  2. On-Campus Residential Buildings

  3. Non-Campus Property: Any building or property owned or controlled by a student organization that is officially recognized by the institution; or any building or property owned, controlled or leased by an institution that is used in direct support of, or in relation to, the institution’s educational purposes, is frequently used by students, and is not within the same reasonably contiguous geographic area of the institution.

  4. Public Property: All public property, including thoroughfares, streets, sidewalks, and parking facilities, that is within the campus, or immediately adjacent to and accessible from the campus.

For Clery purposes, the student status of the offender or victim is not a relevant fact in whether or not this report form is to be completed. If a violation of one of the offenses indicated below occurs, documentation is required.

Clery documentation is not satisfied by simply directing/referring the reporting party to the police department. In order for MTSU to satisfy the statistical reporting requirement of the Clery Act, all CSAs are required to complete this form when any of the specified offenses are reported to them. A person reporting a crime shall be encouraged to report the crime to University Police.

Sex Offenses are of special concern to the campus community because they have been historically under reported. The victim of a sex offense often desires confidentiality and anonymity; as a result he or she may often seek a reporting source other than law enforcement such as a Campus Security Authority. Because the offender may continue to pose a threat to the community, the threat potential needs to be evaluated and the campus alerted or warned as necessary. To accomplish this, the following information is requested.

Title IX: Victims of sexual assault should also be encouraged to report the crime to the Title IX Coordinator or one of the Title IX Deputy Coordinators.

Collecting this information can be valuable in establishing the circumstances surrounding the crime, or establishing a pattern of offender behavior; it in no way assigns blame to the victim of the crime.


Definition of a Campus Security Authority (CSA)

  1. Individuals having responsibility for campus security, who are not members of the university law enforcement department, such as those responsible for monitoring the access to university facilities or property.
  2. All employees, including student employees, who work in a position where they control or monitor access to some part of campus.
  3. Any person or organization specified by University Police in the Annual Security Report as one to which students and employees should report criminal offenses.
  4. All university officials who have significant responsibility for student and campus activities, except pastoral and professional counselors when functioning as such.


Complete this form with as much information and detail as possible.

If the reported incident constitutes a threat to the safety of the MTSU community, prior to completing this form, the CSA shall immediately telephone University Police at 898-2424.

Confidential and anonymous reports are accepted. If the reporting party is a victim of a sex offense, then the victim shall also be encouraged to report the incident directly to the police department and/or the Title IX Coordinator.

Use of this form does not replace or change any existing reporting requirements or procedures for disciplinary referrals regarding student or employee misconduct.

Hate crimes present a special reporting challenge. Clery requires the CSA to document each reported crime occurrence, and requires the CSA to record the category of prejudice motivating the crime.

Any questions concerning this form or the Clery Act should be directed to the Clery Coordinator at University Police 898-2424.

Crime Definitions

  • Murder/Non-negligent Manslaughter
    • The willful (non-negligent) killing of a human being by another.
  • Negligent Manslaughter
    • The killing of another human being through gross negligence.
  • Sex Offenses
    • Rape: Penetration, no matter how slight, of the vagina or anus with any body part or object, or oral penetration by a sex organ of another person, without the consent of the victim.
    • Forcible Fondling: The touching of the private body parts of another person for the purpose of sexual gratification.
    • Incest: Non-forcible sexual intercourse between persons who are related to each other within the degree wherein marriage is prohibited by law.
    • Statutory Rape: Non-forcible sexual intercourse with a person who is under the statutory age of consent.
  • Robbery
    • The taking or attempting to take anything of value from the care, custody, or control of a person by force or threat of force or violence and/or by putting the victim in fear.
  • Aggravated Assault
    • An unlawful attack by one person upon another for the purpose of inflicting severe or aggravated bodily injury.
  • Burglary
    • The unlawful entry of a structure to commit a felony or a theft.
  • Motor Vehicle Theft
    • The theft or attempted theft of a motor vehicle.
  • Arson
    • Any 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.
  • Hate Crimes
    • Any criminal act against a person, group of persons, or the property of any person or group of persons involving one or more of the above listed crimes, or the crimes of Simple Assault, Intimidation, Vandalism, and Larceny which was motivated by a bias against the victim’s ethnicity, race, national origin, religion, gender, sexual orientation, gender identity, or disability or the perception that the person or group has one or more of these characteristics.
  • Alcohol Violations
    • The unlawful possession, sale, transportation, manufacturing, furnishing alcohol to a minor (under 21 years old), or maintaining an unlawful drinking place.
  • Weapons Violations
    • The unlawful possession or control of any firearm, deadly weapon, illegal knife, or explosive device while on the campus of MTSU.
  • Drug/Narcotic Violations
    • Possession of all drugs, without exception, that are illegal under local or state law. All illegally obtained prescription drugs. The equipment or devices used in the preparation and/or use of illegal drugs. See the Next Page for information about the new reporting requirements for Violence Against Women Reauthorization Act (VAWA).

VAWA Crime Definitions

  • Dating Violence
    • Violence committed by a person who is or has been in a social relationship of a romantic or intimate nature with the victim.
      • The existence of such a relationship shall be determined based on a consideration of the length of the relationship, the type of relationship, and the frequency of interaction between the persons involved in the relationship.
      • For the purpose of this definition
        • A social relationship of a romantic or intimate nature means a relationship which is characterized by the expectation of affection or sexual involvement between the parties.
        • Dating violence can be a single event or a pattern of behavior that includes, but is not limited to, sexual or physical abuse.
        • Dating violence does not include acts covered under the definition of domestic violence.
    • Domestic Violence
      • A felony or misdemeanor crime 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 in which the crime of violence occurred; 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 in which the crime of violence occurred.
      • Domestic violence can be a single event or a pattern of behavior that includes, but is not limited to, sexual, or physical abuse.
    • 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.
      • For the purpose of this definition
        • Course of conduct means two or more acts, including, but not limited to, acts in which the stalker directly, indirectly, or through third parties, by any action, method, device, or means, follows, monitors, observes, surveils, threatens, or communicates to or about, a person, or interferes with a person’s property.
        • Substantial emotional distress means significant mental suffering or anguish that may, but does not necessarily, require medical or other professional treatment or counseling.