2022 CSA Annual Disclosure Form

Current 2022 CSA Annual Disclosure Form
Complete

The CSA Annual Disclosure Form is used by Campus Security Authorities to certify whether they have reported all criminal incidents, arrests or disciplinary actions for Clery Act crimes reported to them in their capacity as a CSA. Only designated Campus Security Authorities should complete this form.

Please check one of the following options below:

From January 1, 2022, to December 31, 2022:

I was not aware of, and did not receive, any reports of criminal incidents, arrests or disciplinary actions for Clery Act crimes.

I was aware of, and received reports of criminal incidents, arrests or disciplinary actions for Clery Act crimes. I certify that I have already reported the crime by submitting a CSA crime reporting form online/reporting it directly to University Police.

I was aware of, and received reports of criminal incidents, arrests or disciplinary actions for Clery Act crimes. I have not yet reported the crime(s). I certify that I will report the crime(s) immediately following the submission of this form by completing the CSA crime reporting form online or by contacting University Police.

Name:

Title and Department:

Telephone Number:

Email:

Date:

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