Crime Report Form

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

Additional Party #1
   Name or Organization
   Role ---Involved Person/StudentWitnessOther
   Mesalands ID Number
   Date of Birth
   Phone or Email

Additional Party #2
   Name or Organization
   Role ---Involved Person/StudentWitnessOther
   Mesalands ID Number
   Date of Birth
   Phone or Email

Additional Party #3
   Name or Organization
   Role ---Involved Person/StudentWitnessOther
   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)
Alcohol ViolationArsonAssaultBurglaryCriminal MischiefDiscrimination Based CrimesDisorderly ConductDisturbing the PeaceDistribution of Controlled SubstancesDomestic AssaultExplosive ViolationFalse ImprisonmentForgeryGamblingHazingInhaling or drinking certain intoxicating substancesKidnappingLitteringManslaughterMinor in possession/consumptionMotor Vehicle TheftMurderPanderingPossession of Controlled SubstancePossession of Drug ParaphernaliaProstitutionPublic IndecencyProtection Order ViolationRobberySexual AssaultStalkingStrangulationTerroristic ThreatsTheft by Unlawful TakingUnlawful IntrusionWeapons ViolationOther – Please Describe Below

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