CSA Reporting Form CSA Clery Reporting FormThis is NOT a police report. Please contact the police to file a report.Acknowledgement* I acknowledge that this report is not an emergency or crime in progress. If you have a report of an emergency or crime in progress, please call 9-1-1.CSA InformationCSA Name* Last Name, First NameCSA Title* Do not write CSA. Write your specific title/role.CSA Department* CSA Email Address* CSA Phone Number* Date Report Received mm/dd/yyyyCSA Received Report From Victim Witness Friend Offender Family Other CSA Received the Report From (continued) Mines Student Mines Faculty Member Mines Staff Member Non-Mines Community Member Specify "Other": Additional InformationIncident InformationCrime Committed*Select all that apply. Domestic Violence: A Felony or misdemeanor crime of violence committed i. By a current or former spouse or intimate partner of the victim; ii. By a person with whom the victim shares a child in common; iii. By a person who is cohabitating with, or has cohabitated with, the victim as a spouse or intimate partner; iv. 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 v. 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. 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. i. The existence of such a relationship shall be based on the reporting party’s statement and with consideration of the length of the relationship, the type of relationship, and the frequency of interaction between the persons involved in the relationship. ii. For the purpose of this definition: a. Dating Violence includes, but is not limited to, sex or physical abuse or the threat of such abuse. b. Dating Violence does not include acts covered under the definition of domestic violence. iii. For the purpose of complying with the requirements of this section and §668.41, any incident meeting this definition is considered a crime for the purpose of Clery Act reporting. Stalking: i. Engaging in a course of conduct directed at a specific person that would cause a reasonable person to a. Fear for the person’s safety or the safety of others b. Suffer substantial emotional distress. ii. For the purposes of this definition a. Courses of conduct means two or more acts, including, but not limited to, acts which the stalker directly, indirectly, or through third parties, by an action, method, device, or means follows, monitors, observes, surveils, threatens, or communicates to or about, a person, or interferes with a person’s property. iii. For the purposes of complying with the requirements of this section and section 668.41, any incident meeting this definition is considered a crime for the purposes of Clery Act reporting. Aggravated Assault: An unlawful attack by one person upon another for the purpose of inflicting severe or aggravated bodily injury. This type of assault usually is accompanied by the use of a weapon or by means likely to produce death or great bodily harm. (It is not necessary that injury result from an aggravated assault when a gun, knife, or other weapon is used which could and probably would result in serious personal injury if the crime were successfully completed.) Sexual Assault (Fondling): Fondling is defined as the touching of the private parts of another person for the purposes of sexual gratification, without the consent of the victim, including instances where the victim is incapable of giving consent because of their age or because of their temporary or permanent mental incapacity. Sexual Assault (Rape): Rape is defined as the penetration, not matter how slight, of the vagina or anus with anybody part or object, or oral penetration by a sex organ of another person, without the consent of the victim. Sexual Assault (Incest): Incest is defined as sexual intercourse between a person who are related to each other within the degrees wherein marriage is prohibited by law. Sexual Assault (Statutory Rape): Statutory Rape is defined as sexual intercourse with a person who is under the statutory age of consent (In Colorado the age of consent is defined as: at the time of the commission of the act, the victim is less than fifteen years of age and the actor is at least four years older than the victim and is not the spouse of the victim; or at the time of the commission of the act, the victim is at least fifteen years of age but less than seventeen years of age and the actor is at least ten years older than the victim and is not the spouse of the victim). Hate Crime: A crime reported to local police agencies or to a campus security authority that manifests evidence that the victim was intentionally selected because of the perpetrator’s bias against the victim. The categories of bias include the victim’s actual or perceived race, religion, gender, gender identity, sexual orientation, ethnicity, national origin, and disability. Homicide: The willful (non-negligent) killing of one human being by another. Manslaughter: The killing of another person through gross negligence. Robbery: The taking or attempting to take anything of value from the care, custody, or control of a person or persons by force or threat of force or violence and/or by putting the victim in fear. Burglary (excluding auto burglary): The unlawful entry of a structure to commit a felony or a theft. For reporting purposes this definition includes: unlawful entry with intent to commit a larceny or felony; breaking and entering with intent to commit a larceny; housebreaking; safecracking; and all attempts to commit any of the aforementioned. An incident must meet the following three conditions to be classified as a Burglary: 1. There must be evidence of unlawful entry (trespass). Both forcible and non-forcible entry is included. 2. The unlawful entry must occur within a structure, which is defined as having four walls, a roof, and a door. 3. The unlawful entry into a structure must show evidence that the entry was made in order to commit a felony or theft. If the intent was not to commit a felony or theft, or if the intent cannot be determined, the proper classification is Larceny. Motor Vehicle Theft: The theft or attempted theft of a motor vehicle. (Classify as motor vehicle theft all cases where automobiles are taken by persons not having lawful access even though the vehicles are later abandoned including joyriding.) 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, personal property of another, etc. Other Specify "Other": How Hate Crime was Committed(In conjunction with above and/or below listed incidents) Bodily Injury Theft Vandalism E-Messaging Intimidation Telephone Other Specify "Other": Include Gender BiasIf applicable to hate crime information. Gender Gender Identity Race Religion Disability Ethnicity Sexual Orientation National Origin Victim* Mines Student Mines Faculty Member Mines Staff Member Unknown Victim (stranger) Other Specify "Other": Offender* Mines Student Mines Faculty Member Mines Staff Member Unknown Offender (Stranger) Other Specify "Other": Location of Incident* Off Campus On-Campus (excluding student housing) On-Campus student housing Unknown Location Other On-Campus Student Location (Housing)* Alpha Phi House Alpha Tau Omega House Aspen Hall Beta Theta Pi House 1750 Jackson Bradford Hall Elm Hall Kappa Sigma House Spruce Hall Maple Halls Mines Park Apartment Morgan Hall Phi Gamma Delta House Pi Beta Phi House Randall Hall Sigma Alpha Epsilon House Sigma Kappa House Sigma Phi Epsilon House Thomas Hall Weaver Towers On-Campus Student Location (not housing) Date of Incident* mm/dd/yyyyDescription of Incident* CAPTCHA
