Clery Act Crime Survey Form

The Clery Act applies to certain crimes (see Clery Act Crime Categories) occurring on University property (see Clery Act Reportable Locations) reported to the police (either UNL Police Department or another law enforcement agency) and/or University officials known as Campus Security Authorities (CSA). CSA’s are mandated crime reporters per the Clery Act. As such, CSA’s shall report, on a timely basis or upon request, any Clery-defined crimes to which they become aware to the University’s Accreditation/Compliance Manager (ACM)*, who will use the submitted information to verify the appropriate classification of the crime per the Clery Act. As such, it is important to provide sufficient incident detail to allow for this determination. The purpose of this form is to capture the required information as completely and easily as possible. Please see Campus Security Authorities for additional information on CSA functions and responsibilities.

Anonymity/confidentiality – If a reporting party requests anonymity or confidentiality, this request must be honored to the extent permitted by law. Accordingly, no information should be included on this form that would personally identify the victim without his/her consent.

Submission – To send the completed report electronically, please click the "Submit" button at the end of this form. You may also print this form and either fax (402-472-7972), mail to UNL Police Department (300 N. 17th St, Lincoln, NE 68588 – Attention: Accreditation/Compliance Manager), or email to updaccreditation@unl.edu.

*This requirement is only applicable for crime reports to CSAs that have not been forwarded to the UNL Police Department (i.e. the victim clearly does not want law enforcement notified).

• Agency Name:
  
• First Name:
  
• Last Name:
  
• Title/Rank:
  
• Phone:
  
  --
• or
• E-Mail:
  

• Specific Incident
  Annual Reporting Verification
  No Crime Reports
  Reportable Crime

• Has your agency previously completed a Clery Act Crime Reporting Form in the current calendar year and addressed the unfounding of any crimes occurring on UNL property?
  
  Yes
  No
• In the preceding calendar year, did your agency unfound any crimes that were reported to have occurred at the specified UNL property in your jurisdiction?
  
  Yes
  No
• Please identify the crime type and provide a thorough explanation for why it was unfounded.
  

• Date crime was reported:
  
  //
• Crime occurred on? unknown date single day multiple days
• Date of occurrence:
  
  //

  —

  //

• Location:
  
• Did the crime occur at a University sponsored activity or event?
  
  Yes
  No
  Unknown

• Was the reporting party the crime victim?
  
  Yes
  No
• Is the reporting party unknown?
  
  Yes
  No, but requested anonymity and/or confidentiality (can’t provide name).
  No, and provided his/her name and contact information.
• Reporting Party Contact Information:
  
  • First Name:
    
  • Last Name:
    
  • Phone:
    
    --
  • or
  • E-Mail:
    

• Was the crime motivated by a bias or the victim targeted due to prejudice (i.e. hate crime)?
  
  Yes
  No
• Crime Type:
  
  Murder/Non-negligent Manslaughter
  Negligent Manslaughter
  Forcible Sex Offense
  Non-forcible Sex Offense
  Robbery
  Aggravated Assault
  Burglary
  Motor Vehicle Theft
  Arson
  Dating Violence
  Domestic Violence
  Stalking

  Other:
  

  Simple assault
  Larcency-theft
  Intimidation
  Destruction/damage/vandalism of property
• The crime appeared to be motivated due to the follow bias:
  
  Race
  Religion
  Sexual orientation
  Gender
  Disability
  Ethnicity
  National origin
  Gender identity
• Number of Crime Victims:
  
  ▲

  ▼
   
  Please provide a brief description of the reported incident to aid in its classification:
  
• Law Violations per UCR (arrests only):
  
  ▲

  ▼

  Weapons (e.g. Carrying, Illegal Possessing, etc.)

   
  

  ▲

  ▼

  Drug Abuse

   
  

  ▲

  ▼

  Alcohol/Liquor

• None
  University of Nebraska-Lincoln Police Department
  Lincoln Police Department
  Lancaster County Sheriff's Office
  Nebraska State Patrol
  Other: