Campus Security Authority Report Form

Purpose of Report

According to the Jeanne Clery Disclosure of Campus Security Policy and Campus Crime Statistics Act, UW-Green Bay must collect certain campus crime statistics. This law applies to certain crimes or policy violations reported to any identified Campus Security Authority or similiar campus official.

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Your full name:

Your position/title:

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i.e. Faculty, Staff, or Student Employee

Your campus phone number:

Your UWGB email address:

Email address must be of a valid format.

Nature of this report(Required):

This field is required.

Response Requested(Required):

This field is required.

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What type of follow-up to you believe is necessary for this incident?

Date of Incident(Required):

This field is required.

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Estimate if date is unknown. If behavior occurred on multiple dates, enter date of first incident

Time of incident if known:

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If unsure of time, please make your best estimate.

Location of incident(Required):

This field is required.

Specific location:

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Please enter a room number and building, or description of the location if in a common or open area.

Involved Parties

Involved parties would be anyone who was involved in the act, a victim of the act, or a witness to the act. Please complete all fields to the best of your ability. Individuals may remain anonymous if they wish.

Name or Organization

Select Gender

Select Role

Phone number

Email address

Either campus or local address

Questions

Supporting Documentation

Photos, video, email, and other supporting documents may be attached below. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

Email me a copy of this report

Purpose of Report

Involved Parties

Questions

Supporting Documentation

Submission