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College Crime Watch
9200 S. Dadeland Blvd.
Suite417
Miami, FL 33156
305-670-2409
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Census Survey

Every College Crime Watch program should fill out a CCW Census Survey each autumn. Use the online form below or print out the PDF version (41 kB).

Section A. Contact Information

Institution Name:	(college or university name)
Email:
Group Web Site :
Institution Web Site :
Telephone:	Fax:
Address:
City:	State: Zip:
County:

Check one:
	Private Institution
	Public Institution
Check one:
	Official partnership with institution
	Student-led club only
-------------------------------------
Advisor/Sponsor Name:	(first and last)
Position/Title:
	Administration
	Public Safety
Email:
Day Phone:
Office Phone:
Mobile Phone:
Pager:
CCW President Name:	(first and last)
CCW President Email:
Supporting Administrator:	(first and last)
Supporting Admin Email:
Supporting Admin Phone:

Section B. Participant Information

	Number of youth in Core Group (The core group is the group of students [4-6] who are in charge of running the program. For example, the President, Vice-President, Secretary, etc.)
	Number of youth in Extended Core Group (The extended core group is the rest of members in the CCW program. The officers are not to be included in this count)
	Total number of participating CCW members (This number should reflect the sum of core group members and the extended core group members. For example, if you have 4 in your core group and 15 in your extended core group, the total number of participating YCW members should be 19)
	Total number of youth at site (This is an estimate number of the population in your college or university)
	Estimated hours of CCW participation per month (Add number of hours of all CCW students. For example, 5 youth x 2 hrs = 10 hrs )
Ethnicity of CCW participants (Please give us the percentage of group makeup in your program. For example, 50% Hispanic, 25% Asian, and 25% African American)
%	African American	%	Asian
%	Caucasian	%	Hispanic
%	Indian	%	Other

Section C. Program Information

Date CCW Site Started (This date should reflect when your CCW program was first implemented in your institution)
Problems addressed (These problems are the ones that have been pinpointed by members and are to be addressed with the help of your program components. They are also problems by which your school or community is affected.)
	violence / assault		sexual assault / rape
	theft		off-campus crime
	vandalism		alcohol abuse
	hate crimes		suicide
	drugs
	residential safety	other:
Program Components: (These are the components that your site is presently implementing in your program in order to address your school or community's problems)
	action projects
	campus watch
	escort services and campus patrols
	peer mediation / counseling
	drug and alcohol abuse prevention education
	lifesaving
	hate crime prevention
	crime reporting
	self-defense training
Do you have organizational partners supporting your CCW program? (e.g., other schools, law enforcement agencies, businesses, etc.)

Section D. Level of Training

Has your site attended any of our events? Yes No If so, which ones?
	Conference When? How many went?
	Conference calls When? How many participated?
	Implementation training When? How many went?
	Leadership retreat When? How many went?

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