CSA Incident Report
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Date Incident Reported to CSA:
CSA Contact Information
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First Name:
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Last Name:
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Phone:
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Email:
Incident Details
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Incident Occured On:
A Specific Date
A Range of Dates
An Unknown Date
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Date Incident Occured:
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Incident Date Range:
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Incident Type (select at least 1):
Homicide & Manslaughter
Aggravated Assault
Rape - Including Sodomy or Sexual Assault with Object
Fondling
Statutory Rape - Victim under Legal Age of Consent
Incest
Burglary
Robbery
Motor Vehicle Theft
Arson
Bias Motivated - Vandalism
Bias Motivated - Theft
Bias Motivated - Simple Assault
Bias Motivated - Intimidation
Dating Violence
Domestic Violence
Stalking
Liquor Law Violation
Drug Law Violation
Weapon Law Violation
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Location:
-- Select Location --
On Campus - Residence Hall
On Campus - Non-Residence Hall
Public Property - Immediately Adjacent to Campus (sidewalk, street)
Non Campus - Owned/Leased/Controlled by UMBC
Unknown
Address:
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Incident Description:
Please provide specific, detailed information related to the reported incident(s), including the relationship between the victim and suspect.
Do NOT identify the victim if confidentiality is requested.
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Bias Motivated:
Yes
No
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Bias Category:
-- Select Category --
Race
Religion
National Origin
Ethnicity
Disability
Sexual Orientation
Gender
Gender Identity
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Brief Summary of Evidence
Supporting Bias:
characters (250 maximum)
Other Department(s) or CSA(s) Notified:
Victim or Witness Contact Information (do not put your own information)
Do NOT enter victim's contact information if confidentiality is requested.
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Incident Disclosed by:
-- Select --
Victim
Third Party
Relationship to Victim:
First Name:
Last Name:
Phone Number:
Email:
Does the victim wish to be contacted by law enforcement?
Yes
No
Attachment:
Choose File(s)
Warning: Sending documents with highly sensitive information, ie. social security numbers, is not recommended.
Notes/Comments:
characters (250 maximum)
* = Required field. You must fill in all required fields.