Campus Security Authority Report

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If this is an emergency or on-going crime call University Police at 931-372-3234 or dial 911.

This form should be utilized by Tennessee Tech Campus Security Authorities (CSA) to report crimes to the Clery Coordinator. The information provided in this form will be used to classify the crime for purposes of inclusion in Tennessee Tech’s Annual Campus Security and Fire Safety Report.

Date Incident reported to CSA*

CSA Full Name*

Position/Title*

Department*

Phone or Tennessee Tech Ext.*

Email*

Date incident occurred

Location Name/Address*

Location classification (select one)

Victim/Suspect Relationship

Was this incident motivated by bias?YesNoUnknown

Incident Description - Provide specific information related to the reported incident*

To your knowledge, was this incident reported to a law enforcement agency (i.e. University Police, Cookeville City Police, etc.)??YesNoUnknown

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