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Campus Security Authority Clery Act

Incident Report Form

This form shall be used by Campus Security Authorities (CSA) to report suspected crime and incident data to the Department of Public Safety as required by the Jeanne Clery Act. CSA's are required to document certain reportable crimes and non-criminal hate motivated incidents which have been reported to them and which have occurred in certain locations. The details of this report will not be made public. Only the number of crimes occurring will be released. In the event the reported incident represents a serious or continuing threat to the college community, a timely warning may be required. Under those circumstances, this form must be completed and forwarded immediately to the Department of Public Safety.

Reporting Information

If a reporting person requests anonymity, this request must be honored to the extent permitted by law. Under those circumstances, write "ANONYMOUS" in place of their name below. Further, no information should be included on this form that would personally identify the victim without his/her consent.

Each year Middlesex Community College publishes an Annual Security Report, as required by the Crime Awareness and Campus Security Act of 1990 (the “Clery Act”). MCC is required to compile and publish statistics regarding the occurrence of certain criminal offenses that are reported either to the local police agency or to any official of the college who is considered to be a Campus Security Authority under the Clery Act.

The details of this report will not be made public only the number of crimes occurring will be released. In addition, your name will not be released. This form should be submitted when there is a report from a student, an employee or third party. The College’s Clery Compliance Administrator will use this information to verify the appropriate classification of the incident/crime.
Reporting Party*
 *Do not provide the reporting person’s name or information if there is a request to remain anonymous. Based on the College’s obligations to Title IX, reports of sexual harassment or sexual violence must be reported to the Title IX Coordinator, Pamela Medina.
Incident /crime information
Incident/crime classification
Please Select one of the options below:*
Per the Clery Act, the criminal offenses listed above, as well as theft, simple assault, intimidation, vandalism and any other crime involving bodily injury are reportable as a hate crime if a crime was motivated by the offender's bias. For information on Hate Crime definitions refer to the "CSA Crime Report Form Definitions" resource or contact the MCC Clery Compliance Administrator (russl@middlesex.edu).
Is there evidence that this incident/crime was motivated by bias?*
If yes, please check all that apply: *
By submitting this form, it will be sent electronically to the Clery Compliance Administrator. A hard copy can be requested by e-mailing russl@middlesex.edu.
Campus Security Authority information