Campus Security Authority Crime Report Form
A.T. Still University is required to report certain crimes in compliance with the Jeanne Clery Disclosure of Campus Security Policy and Campus Crime Statistics Act (Clery Act) and to publish the crime statistics each year in its Annual Security Reports (ASR).

When a crime is reported to a CSA by a student, employee, or other individual, the CSA must immediately complete and submit this Crime Report Form. For questions, contact ATSU Security or Dawn Shaffer, compliance manager.

For more information about the Clery Act and the responsibilities of CSAs, see the ATSU website below: https://www.atsu.edu/office-of-vice-president-and-general-counsel/compliance#clery-act-compliance
Email address *
CSA name *
CSA contact telephone number *
Person reporting crime to CSA name
Person reporting crime to CSA email
Person reporting crime to CSA telephone number
The reporting person is a: *
Date incident reported to CSA *
MM
/
DD
/
YYYY
Date incident occurred *
MM
/
DD
/
YYYY
Time incident occurred *
Time
:
Location: Please provide the specific location where the incident occurred (e.g., building name, room number, address, street name with cross streets or close address, nearby building if it occurred outside). *
Description: Please provide a description of the incident. *
Is there evidence this crime was motivated by bias? *
If "yes", identify the potential category of bias. Check all that apply.
Submit
Never submit passwords through Google Forms.
This form was created inside of A.T. Still University of Health Sciences. Report Abuse