Clery Travel Form

There are a number of reporting elements required for compliance with the Clery Act. This page is focused on helping you to report Clery‐mandated travel information. There are specific variables that we will work to verify to determine if your trip is reportable. Once we do that, we will ask you follow‐ up questions, as necessary, to complete the reporting. Before we get started, it is helpful for you to have the trip documents at hand, including the address and arrival/departure dates at any accommodations at which you stayed.

For incident queries/questions or to make a report: secure-clerycsa@lists.stanford.edu
For general CLERY information, contact: lwade@stanford.edu Phone: (650)‐723‐4928

Step 1

Yes

No

1. Did students accompany you to or at this destination?

Step 2

Yes

No

2. Were the accommodations a home‐stay at a residence, for the entire trip?

Step 3

Contact Information

Organization Name*

Department Name*

Name*

Position Title

Email*

Travel Description

Add more Remove

<div class="maindiv" id="maindiv-{0}">
                            <div class="form-g four-colmn">
                                <label>Location Name</label>
                                <input type="text" name="locationname[]" id="locationname-{0}" class="input-control" placeholder="Location Name">
                            </div>
                            <div class="form-g four-colmn">
                                <label>Address 1<span class="mand">*</span></label>
                                <input type="text" name="address1[]" id="address1-{0}" class="input-control" placeholder="Address 1">
                            </div>

<div class="form-g four-colmn">
                                <label>Address 2</label>
                                <input type="text" name="address2[]" id="address2-{0}" class="input-control" placeholder="Address 2">
                            </div>
                            <div class="form-g four-colmn">
                                <label>City</label>
                                <input type="text" name="city[]" id="city-{0}" class="input-control" placeholder="City">
                            </div>
                            <div class="form-g five-colmn">
                                <label>State/Province</label>
                                <input type="text" name="stateprovince[]" id="stateprovince-{0}" class="input-control " placeholder="State/Province">
                            </div>
                            <div class="form-g five-colmn">
                                <label>Zip Code</label>
                                <input type="text" name="zipcode[]" id="zipcode-{0}" class="input-control " placeholder="Zip Code">
                            </div>
                            <div class="form-g five-colmn">
                                <label>Country</label>
                                <input type="text" name="country[]" id="country-{0}" class="input-control" placeholder="Country">
                            </div>
                            <div class="form-g five-colmn">
                                <label>Begin Date</label>
                                <input type="text" name="begindate[]" id="begindate-{0}" class="input-control datepicker" placeholder="mm/dd/yyyy" readonly="">
                            </div>
                            <div class="form-g five-colmn">
                                <label>End Date</label>
                                <input type="text" name="enddate[]" id="enddate-{0}" class="input-control datepicker" placeholder="mm/dd/yyyy" readonly="">

</div>
                        </div>

Step 4

No

Yes

4. Finally, were you, or anyone in your party, a victim of or witness to a crime while at this location?