Winona State University Logo

Campus Security Authority (CSA) Report Form


The CSA Report Form is to be used by Campus Security Authorities (CSAs) or individuals who believe they may be a Campus Security Authority, to report Clery Act crimes. CSAs are responsible for reporting allegations of Clery Act Crimes that are reported to them in their capacity as a CSA. CSAs are not responsible for determining whether a crime took place. 

In an emergency, call 911.

In most cases it is possible for a CSA to fulfill thier responsibility while withholding personally identifiable information. 

This CSA report does not automatically result in the initiation of a police or disciplinary investigation. If the victim would like to pursue disciplinary action direct them to the Director of Affirmative Action/Equity, Lori Mikl 457-5008.

Fill out as much information as possible when using this form. If you do not know the information leave it blank. It is not your duty to investigate the incident, but rather it is your duty to report the incident.

To ensure proper Clery Act classification of the incident being reported, the contact information of the person filling out this form is being requested. Contact will be limited and only initiated if the Director of Security needs further assistance in the proper classification of the incident.

If you need assistance in filling out this form please contact the Director of Security, Chris Cichosz, at 457-5555.

Introduction

Campus Security Authorities are federally mandated crime reporters. CSAs shall report, in a timely manner, any Clery Act crimes that they are made aware of to Campus Security by using this form. It is important for CSAs to document sufficient incident details to allow for proper classification of the crime(s).

 
Email address must be of a valid format.
This field is required.
Learn more
If a range of dates include it in the narrative.
Learn more
If a range of time include it in the narrative.
This field is required.
Learn more
Did the incident take place outside, inside, in hallway, on the sidewalk, what floor, etc.

Involved Parties

Anonymity– If a crime reporting party requests anonymity, this request must be honored to the extent permitted by law. Accordingly, no information should be included on this form that would personally identify the victim without his/her consent.

Involved party 1

Reported Crime

Crime Reporting – It is the policy of Winona State University to ensure that the victims of crimes are aware of their right to report criminal acts to law enforcement. CSAs should ask the reporting party if they would like to report the crime to law enforcement. If the reporting party would like law enforcement contacted the CSA should assist the victim in the request.




Sexual Incidents– CSAs reporting a student or employee reported incidence of sexual violence are encouraged to provide campus/community resources as well as direct them to the WSU Sexual Violence website or contact the 24/7 Confidential GBV Helpline at 507-452-4453.

Check the box that best indicates the crime you are reporting. As needed, click Clery Act Crimes for crime definitions. You can select multiple crimes.(Required)
You must make at least one selection.
This field is required.
Hate Crimes- The following crimes also need to be reported, for Clery Act purposes, if the victim(s) of the reported crime was/were targeted specifically because of bias/prejudice against the victim based on race, religion, gender, gender identity, ethnicity, national origin, or disability. As needed, click Clery Act Crimes for definitions.(Required)
You must make at least one selection.
This field is required.
If a liquor, drug, or weapon law violation is reported, the corresponding number or persons referred must be entered. Please select the applicable violation below if it pertains to your report. As needed, click Clery Act Crimes for alcohol, drug and weapons violation definitions.
You must make at least one selection.
This field is required.
This field is required.
This field is required.
This field is required.
This field is required.
This field is required.

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.

Submission