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CSA Report Form
Name of Person Reporting
*
First
Last
Email Address of Person Reporting
Your Phone Number
Campus Security Authority Incident Report Form
Do you know what date this incident happened?
*
Yes
No
Please provide estimated date or date range.
*
Date that Incident Occurred
*
MM slash DD slash YYYY
Do you know what time this incident happened?
*
Yes
No
Please provide estimated time or general time frame.
*
Time that Incident Occurred
*
:
Hours
Minutes
AM
PM
AM/PM
Name of Victim (unless confidential or N/A):
First
Last
Location of Incident
On Campus
Off Campus
Did the incident occur inside or outside?
In the barracks
In another building
Outside
Please choose which barracks:
Trustees Hall (Alpha Company Barracks)
Lovelace Hall (Bravo Company Barracks)
Rane Hall (Charlie Company Barracks)
Wilkerson Hall (Delta Company Barracks)
Murfee Hall (Echo Company Barracks)
Which floor?
Which room, if applicable?
Please choose which building:
North Academic Wing (Right side of Chapel)
South Academic Wing (Left side of Chapel)
Administration Building
Alumni Gymnasium/Fitness Center/Weight Room
Baer Memorial Library
Bookstore/Mailroom
Chapel
Dining Hall
Guardhouse
Ireland Athletic Center/Gym/Pool
Johnson Hall
Middlebrooks Hall/Music Building
Monteabaro Complex/Chemistry Building
Robinson Excess House
Other
If you need to lookup the name of the building, please view the campus map: https://marionmilitary.edu/about-mmi/campus-map/
Please enter the floor and room number, if applicable
Please describe the location here:
Please choose an outdoor area, if possible. If it was not in a definable location, please select "Other" and describe the location and nearest buildings, roads, etc.
Cadet Parking Lot
Chemistry Parking Lot/ Event Parking Lot
Davis Baseball Field
Golf Course
Honor Ground
Leadership Training Complex
Givhan Parade Field
Quad
Robinson Stadium
Soldier's Field (Softball Field)
Swamp Fox Pit
Anderson Tennis Complex
Visitor Parking
Other
Please describe the location here:
Name(s) of the Accused:
If no names, please describe the offender(s):
If more than one offender, please complete a SEPARATE FORM for each individual offender.
Please describe the incident below. Include names, locations, dates, and times when possible.
*
Type of Offense
Please use the definitions below to categorize the type of offense that might correlate with this incident.
One or more choice(s) may be selected:
Criminal Offense
Hate Crime
VAWA Offense
Law Violation
Criminal Offenses
Criminal Homicide (including Murder and Non-negligent Manslaughter); Manslaughter by Negligence; Sexual Assault (including Rape, Fondling, Incest and Statutory Rape); Robbery; Aggravated Assault; Burglary; Motor Vehicle Theft; and Arson.
Please select one or more appropriate definitions below if this incident could be classified as a Criminal Offense:
Murder and Non-negligent Manslaughter: the willful (non-negligent) killing of one human being by another
Manslaughter by Negligence: the killing of another person through gross negligence
Rape: the penetration, no matter how slight, of the vagina or anus, with any body part or object, or oral penetration by a sex organ of another person, without the consent of the victim. This offense includes the rape of both males and females. Count one offense per victim.
Fondling: the touching of the private body parts of another person for the purpose of sexual gratification, without the consent of the victim, including instances where the victim is incapable of giving consent because of his/her age or because of his/her temporary or permanent mental incapacity. Count one offense per victim.
Incest: sexual intercourse between persons who are related to each other within the degrees wherein marriage is prohibited by law. Count one offense per victim.
Statutory Rape: sexual intercourse with a person who is under the statutory age of consent. Count one offense per victim.
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. count one offense for each distinct operation (i.e., incident), including attempts. Do not count the number of victims robbed, the number of those present at the Robbery or the number of offenders.
Aggravated Assault: an unlawful attack by one person upon another or 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. Count one offense per victim.
Burglary: the unlawful entry of a structure to commit a felony or a theft. Count one offense per each distinct operation.
Motor Vehicle Theft: the theft or attempted theft of a motor vehicle. Count one offense for each stolen vehicle.
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.
Larceny-Theft, Simple Assault, Intimidation, and Destruction/Damage/Vandalism of Property are included in Clery Act statistics ONLY IF THEY ARE HATE CRIMES.
Larceny-Theft: the unlawful taking, carrying, leading or riding away of property from the possession or constructive possession of another.
Simple Assault: an unlawful physical attack by one person upon another where neither the offender displays a weapon, nor the victim suffers obvious severe or aggravated bodily injury involving apparent broken bones, loss of teeth, possible internal injury, severe laceration, or loss of consciousness.
Intimidation: to unlawfully place another person in reasonable fear of bodily harm through the use of threatening words and/or other conduct, but without displaying a weapon or subjecting the victim to actual physical attack.
Destruction/Damage/Vandalism of Property: to willfully or maliciously destroy, damage, deface, or otherwise injure real or personal property without the consent of the owner or the person having custody or control of it.
Hate Crimes
Any Criminal Offense OR incidents of Larceny-Theft; Simple Assault; Intimidation; or Destruction/Damage/Vandalism of Property that were motivated by bias.
Please select one or more appropriate definitions below if this incident could be classified as a Hate Crime:
Hate Crime: a criminal offense that manifests evidence that the victim was intentionally selected because of the perpetrator's bias against the victim.
Race: A preformed negative attitude toward a group of persons who possess common physical characteristics, e.g., color or skin, eyes, and/or hair; facial features, etc., genetically transmitted by descent and heredity which distinguish them as a distinct division of humankind, e.g., Asians, blacks or African Americans, whites.
Religion: A preformed negative opinion or attitude toward a group of persons who share the same religious beliefs regarding the origin and purpose of the universe and the existence or nonexistence of a supreme being, e.g., Catholics, Jews, Protestants, atheists.
Sexual Orientation: A preformed negative opinion or attitude toward a group of persons based on their actual or perceived sexual orientation.
Gender: A preformed negative opinion or attitude toward a person or group of persons based on their actual or perceived gender, e.g., male or female.
Gender Identity: A preformed negative opinion or attitude toward a person or group of persons based on their actual or perceived gender identity, e.g., bias against transgender or gender non-conforming individuals.
Ethnicity: A preformed negative opinion or attitude toward a group of people whose members identify with each other, through a common heritage, often consisting of a common language, common culture (often including a shared religion) and/or ideology that stresses common ancestry.
National Origin: A preformed negative opinion or attitude toward a group of people based on their actual or perceived country of birth
Disability: A preformed negative opinion or attitude toward a group of persons based on their physical or mental impairments, whether such disability is temporary or permanent, congenital or acquired by heredity, accident, injury, advanced age or illness.
VAWA Offenses
Any incidents of Domestic Violence, Dating Violence and Stalking. (Note that Sexual Assault is also a VAWA Offense but is included in the Criminal Offenses category for Clery Act reporting purposes).
Please select one or more appropriate definitions below if this incident could be classified as a VAWA Offense.
Domestic Violence
Dating Violence
Stalking
Weapons, Drug, or Liquor Law Violations (Arrests or Referrals for Disciplinary Action)
Law Violations
Weapons: Carrying, Possessing, etc.: the violation of laws or ordinances prohibiting the manufacture, sale, purchase, transportation, possession, concealment, or use of firearms, cutting instruments, explosives, incendiary devices or other deadly weapons. This classification encompasses weapons offenses that are regulatory in nature.
Drug Abuse Violations: the violation of laws prohibiting the production, distribution and/or use of certain controlled substances and the equipment or devices utilized in their preparation and/or use. The unlawful cultivation, manufacture, distribution, sale, purchase, use, possession, transportation or importation of any controlled drug or narcotic substance. Arrests for violations of state and local laws, specifically those relating to the unlawful possession, sale, use, growing, manufacturing and making of narcotic drugs.
Liquor Law Violation: the violation of state or local laws or ordinances prohibiting the manufacture, sale, purchase, transportation, possession or use of alcoholic beverages, not including driving under the influence and drunkenness.
Was the offender under the age of 21?
Yes
No
Was the offender in possession of alcohol?
Yes
No
Was this an arrest or referral for disciplinary action?
Arrest
Referral for disciplinary action
Anonymity Statement
The Deputy Vice President of Student Affairs & Deputy Commandant of Cadets and the Assistant Commandant for Operations and Administration will automatically receive a copy of this report. No information regarding the reporter's identity will be shared with anyone besides pertinent members of the Commandant's staff.
Digital Signature
*
Date
*
MM slash DD slash YYYY
