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Touro University California Campus Security Authority (Clery) Incident Report Form

CSAs at Touro University California are required to complete this form any time they become aware of a Clery Act crime. The form is routed to the Clery Compliance Committee for inclusion in the university’s annual crime statistics. The CSA Report form is not a method of notifying police of an emergency, dangerous situation, or other hazard. The submission of the CSA Report will not prompt a police or University investigation, generate an official police report, or create a police case number.

IN THE EVENT OF AN EMERGENCY CALL 9-1-1

Campus Security Authority Background Information: Enter your information below in case the Clery Compliance committee needs to contact you for additional information.

Your Full Name:

Your Position/Title:

Your Work Phone Number:

Your Cell Phone Number:

Your Work Email Address:

Your Work Physical Address:

Date Report Submitted:

Involved Parties Information:

Enter the list of individuals involved (excluding yourself), completing as many listed fields as you can provide:

Full Name of Involved Individual:

Individual’s Role at University (student, staff, faculty):

TUC ID Number (if applicable):

Individual’s Touro Email Address:

Role in incident: (victim, accused, etc.)

Incident Details and Narrative:
Enter the information about the Incident and Involved Parties.

Date Incident was reported to you:

Date and Time of Incident:

Location of Incident (please be as exact as possible):

Other Type of Incident: Was this incident was motivated by bias? Please answer Yes or No.

Other Type of Incident: If you believe this incident was motivated by bias, please describe your reasons.

Incident Description (please include as much information as possible):

Please indicate other offices this incident has been reported to

Did you provide a copy of the Notice of Rights and Options:

Yes
No