Campus Security Authority (CSA) – Campus Police – Virginia Western Community College

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Required Information

Campus: *

Date incident reported to CSA: *

Incident Contact Header

Incident Contact Information

First and Last Name:

Phone Number:

Email Address:

Incident Header

Incident Details

Date the incident occurred:

OR Incident Date Range:

OR Date Unknown:

Incident Description:

Incident Category Header

Incident Category - Select All That Apply

Homicide-Murder

Aggravated Assault

Sex Offense (non-forcible)

Sex Offense (forcible)

If forcible sex offense, were the victim and the offender acquainted (did they know each other)?

Yes
No
Unknown

Burglary

Robbery

Motor Vehicle Theft

Arson

Liquor (A) Drug (B) and/or Weapon Law (C) Violation

(A) Liquor - Underage possession or consumption; distribution to minors

Arrest
Disciplinary Referral

(B) Drug - Use; possession or distribution of controlled substances or possession of drug paraphernalia

Arrest
Disciplinary Referral

Arrest
Disciplinary Referral

Dating Violence

Violence committed by a person (A) who is or has been in a social relationship of a romantic or intimate nature with the victim; and (B) where the existence of such a relationship shall be determined based on a consideration of the following factors:

The length of the relationship;

The type of relationship;

The frequency of interaction between the persons involved in the relationship.

Dating violence includes threats of, or use of, physical, sexual, verbal, emotional, economic or psychological action to influence or control the victim.

Domestic Violence

Felony or misdemeanor crimes of violence committed by a current or former spouse or intimate partner of the victim, by a person with whom the victim shares a child in common, by a person who is cohabitating with or has cohabitated with the victim as a spouse or intimate partner, by a person similarly situated to a spouse of the victim under the domestic or family violence laws of the jurisdiction receiving grant monies, or by any other person against an adult or youth victim who is protected from that person's acts under the domestic or family violence laws of the jurisdiction.

Stalking

Other Crime Category:

Agency Notified:

Reported by:

Third Party
Victim

Relation to Victim:

Reporting Party First & Last Name:

Reporting Party Phone Number:

Incident Location:

On Campus
Public Property immediately adjacent to campus (sidewalks, streets, etc.)
Non-Campus in college-owned leased or controlled space
Unknown location, other

Incident Address:

Motivated by Bias:

Prejudice Category:

Disability
Ethnicity
Gender
Gender Identity
National Origin
Race
Religion
Sexual Orientation

Evidence of Bias:

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Once completed, you may submit this form electronically by clicking on the Submit button below or print the form and send to:

Virginia Western Police Department
Attn: Chief Craig S. Harris
3054 Colonial Avenue, SW
Roanoke, Virginia 24015

Campus Security Authority Incident Report Form

Required Information

Incident Contact Information

Incident Details

Incident Category - Select All That Apply

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