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CSA Crime Statistics Reporting Data Form

This form is solely for the purpose of collecting data for statistical reporting required by the Crime Awareness and Campus Security Act, as amended by the Higher Education Amendments of 1998.

Please fill out the secure web-based form below. You also have the option to print the crime reporting form and submit this form in person at the Division of Public Safety, 4040 Chestnut Street, send via email to , or via fax to 215-573-7042.

You may contact Penn Police at any time by visiting department headquarters at 4040 Chestnut Street, calling 215-573-3333 or 511 from any campus phone, or by using one of the many Bluelight and emergency telephones located throughout the campus.

For more on Clery reporting visit www.publicsafety.upenn.edu/clery or call Penn’s Division of Public Safety’s Special Services Department at 215-898-4481 (898-6600 off-hours).

This form is to be completed by University officials with significant responsibility for student and campus activities.

"*" indicates required fields

Verify By Typing Your Name Here
Date
MM slash DD slash YYYY

MM slash DD slash YYYY
MM slash DD slash YYYY
(Name of building, if applicable, street address and room number. NOTE: Room/apartment number may be omitted when the incident reported is of a sensitive nature, and providing this information would jeopardize confidentiality.)
(Do not include information that may reveal identities of involved parties.)

Please Answer the Following Questions About the Incident

Was A Weapon Involved?
Is there evidence that the offense was motivated by bias?
(e.g., faculty, staff, student, visitor, alumni, etc.)
(e.g., faculty, staff, student, visitor, alumni, etc.)
Has this incident been reported to any law enforcement official?