Incident Report Form at WITCC
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Campus Security & Safety
NON-EMERGENCIES
712.274.8733 ext. 6414
EMERGENCIES
712.274.8733 ext. 1316
security@witcc.edu
Safety & Security Supervisor
712.274.8733 ext. 3210

Incident Report Form

This form is to be completed by a College Campus Security Authority (CSA) who is required, under the federal Clery Act, to report information they receive about qualifying crimes. The information collected from these forms will be used to compile statistics to be included in Western Iowa Tech Community College's annual security report.

Do not provide name/contact information if the person reporting the incident requests confidentiality.

The CSA provides as much of the requested information on the form, excluding identity if confidentiality is requested, as s/he knows. The Security Department will use the submitted information to determine the appropriate classification of the incident.

A. (mm/dd/yyyy)
B. CSA contact information  
C. Date(s) of incident occurrence: (choose one)
(mm/dd/yyyy)
(mm/dd/yyyy)
(check here if specific date(s) is not known)
D. (provide specific information related to the report incident)
E. Select the category that best fits the description of the incident you are reporting (click here for definitions)








 
Yes     No     Unknown
** See definitions
Arrest or   Student Referral
Arrest or   Student Referral
Arrest or   Student Referral

F. Victim    Third Party



(xxx-xxx-xxxx)

G. If the incident occurred in multiple places (check all that apply)
On-campus, residence hall
On-campus, not in residence hall
Off-campus, public property immediately adjacent to campus (sidewalks, streets, etc)
Off-campus in College leased or controlled space
Off-campus, NOT affiliated with and NOT adjacent to campus
Unknown location
H. If known, (building name, street address, office number, etc)
   
Per the Clery Act, the following crimes are reportable as Hate Crime (where there is evidence that the incident was motivated by hate or bias): one/more of the crimes listed in section "E" (above); the crimes of Theft, Simple Assault, Intimidation and Vandalism, and any other crime involving bodily injury. For information on Hate Crime definitions click here.
Yes    No
If you answered "No" to the above question, click "Submit Form" at the bottom of the page.
If you answered "Yes" to the above question, complete the following section.
(check all that apply)
Race
National Origin
Religion
Sexual Orientation
Ethnicity
Disability
 
Western Iowa Tech Community College does not discriminate on the basis of race, creed, color, gender, national origin, religion, age, disability, sexual orientation, gender identity, veteran status or any other protected basis as defined in Iowa or federal law as amended from time to time in its educational programs, activities, admission procedures or employment practices. Individuals who believe they have been discriminated against may file a complaint through the College's Grievance or Complaint Procedures. Complaint or Grievance Forms and Procedures may be obtained from the WITCC Human Resources Department, Dr. Robert H. Kiser Building, Room A242, (712) 274-6400, Ext. 1220.
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