CSA Reporting Form

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Some content may be updated based on selection

Department of Public Safety
Crisp Hall
215 Hurt Street
Martin, TN 38238
Office: 731-881-7777

UT Martin Campus Security Authorities Form

Date incident reported to CSA:

First Name:

Last Name:

Position Title:

Department:

Phone:

Email:

Date incident occurred:

When in doubt if an incident occurred on a Clery defined property, CSA's should still submit this completed form. A determination will be made by the
UT Martin Police Department if the location is on Clery defined propery.

Location name/Address:

Location description (sidewalk, roadway, interior, etc.)

Location Classification:

Satellite Campus (Parsons, Ripley, Jackson, Selmer, Somerville)

On-campus, in a residence hall

On-campus, not in a residence hall

Off-campus, public property immediately adjacent to campus (sidewalks, streets, etc.)

Off-campus in university leased or controlled space

Off-campus, not affiliated with and not adjacent to campus

Unknown location

Victim Relationship:

Other

Partner

Ex-Partner

Spouse

Ex-Spouse

Family Member

Was this incident motivated by bias (race, gender, religion, sexual orientation, ethnicity, gender identity, national origin, or disability)?

Yes

Unknown

To your knowledge, was this incident reported to a law enforcement agency or other campus office?

Yes

Who?

Victim Personal Identifier
For tracking purposes and to avoid double counting incidents, please include a victim personal identifier such as the initials of their first, middle, and last
name if available. This information will not be published in Safety Notices or Crime Statistics.

Incident Description - Provide specific information related to the reported incident

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