Clery Act Student Travel Form

This form is to be completed for any College-related overnight travel, domestic and overseas, that includes students such as athletics, academics, clubs/organizations, etc. The federal Clery Act law requires that institutions track what is known as “non-campus” property, and report certain crimes that occur at those locations. Non-campus property includes property that UMW controls on a short-term basis if there is a written agreement for the property, the property is frequented by students, and it is used to further UMW’s educational mission. UMW is required to reach out to the local law enforcement agencies with jurisdiction over non-campus property and request crime statistics for the dates and times when UMW controls the space. UMW must provide the statistics, if any, to the federal government and publish them in the Annual Security and Fire Safety Report.

Please submit this form AFTER your travel to ensure you have complete information, including specific rooms/suites occupied. If you have questions, please contact Nicole Hazelbaker, Dean of Students, at 406-683-7388 or [email protected]

GENERAL INFORMATION

Today's Date *

Group Name *

Name of Person Submitting this Form *

TRAVEL CONTACT INFORMATION

I understand that I am a Campus Security Authority (CSA) for this trip and must report to the UMW Dean of Students in a timely manner any crimes brought to my attention. To report a crime please contact the Clery Compliance Officer at 406-683-7388.

CONTACT INFORMATION

Name (CSA in charge of group) *

Title *

Department *

Phone Number *

Email *

LODGING DATES

Check-in Date *

Check-out Date *

LODGING/FACILITY INFORMATION

If group is staying at more than one lodging facility, please complete a separate form for EACH facility. Additionally, along with lodging, if during the trip the University "controls" any additional spaces (classrooms, meeting rooms, team meal spaces, etc.) please include in the section below marked with #

FACILITY INFORMATION

Name of Facility *

Address of Facility *

Address Line 1

City

State / Province / Region

Postal Code

Country

# Specific floor(s), room number(s), or unit number(s) occupied *

The trip is: *

A one-time trip
Repeated each semester
Repeated annually
Other

If you selected "other" from above, please explain here:

If trip is "repeated", our group:

Always stays at the exact same lodging facility
Uses various lodging facilities with each trip

LAW ENFORCEMENT AGENCY (IF KNOWN)

The University is required to collect and report crime statistics from local law enforcement agencies regarding certain non-campus lodging facilities or other controlled spaces where UMW students are housed or spaces they use during University sponsored overnight student travel. It is critical this information is provided by the CSA's who are travelling with students overseas.

Name of the law enforcement agency having jurisdiction over lodging facility or other controlled space(s):

Address of Law Enforcement Agency

Address Line 1

City

State / Province / Region

Postal Code

Country

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