Mesalands Community College - Crime Report Form

If this is an emergency dial 9-1-1

According to the Higher Education Act, or 20 U.S.C. 1092 now known as the Jeanne Clery Disclosure of Camus Security Policy and Campus Crime Statistics Act, Mesalands Community College must collect campus and learning center crime statistics.

This form is designed to provide students, employees; faculty, vendors, visitors, or others with an on-line method to report any crimes committed on Mesalands Community College’s property or during Mesalands Community College’s sponsored student overnight trips.

You are not required to complete the entire form in order for the information to be submitted. Though anonymous reports are permitted, doing so may limit the College’s ability to investigate and respond to a report. Mesalands Community College will use the information provided to begin an investigation, which may include contacting the involved parties. The College’s ability to respond is improved based on the quantity and quality of information provided.

Your Full Name
Your Phone Number
Date of Incident
Time of Incident
Location of Incident
Specific Location

Additional Party #1
   Name or Organization
   Role
   Mesalands ID Number
   Date of Birth
   Phone or Email

Additional Party #2
   Name or Organization
   Role
   Mesalands ID Number
   Date of Birth
   Phone or Email

Additional Party #3
   Name or Organization
   Role
   Mesalands ID Number
   Date of Birth
   Phone or Email

Select the term that best describes the nature of the incident. You may select more than one term. (Required)

Is there evidence that the victim was intentionally selected because of the perpetrator’s bias against the victim’s race, religion, ethnicity/national origin, sexual orientation, disability, or gender identity?YesNo

Please provide a detailed description of the incident/concern using specific concise, objective language (Who, what, where, when, why, and how). (Required)

If the incident resulted in law enforcement becoming involved, please enter the case number and the agency name below. If case number is unknown then enter “unknown” with the name of the law enforcement agency.

Photos, video, email, and other supporting documents may be attached below. 4MB maximum total size. For larger files please include share links from cloud services such as Dropbox, Google Drive, Microsoft One Drive or YouTube in the URL field below.

Large file or relevant URL

If you would like to receive an email confirmation of this report please provide your email address