SECURITY SURVEY REQUEST FORM

Please complete the non-shaded areas of this form to request the Buffalo State University Police Department to conduct a security survey in your area. Survey location must fall under the purview of the requesting department/office. Once the assessment is complete, UPD will issue recommendations regarding appropriate security/surveillance measures. Subsidization of such measures is neither implied nor implicit. Video surveillance equipment may not be installed without recommendation from the UPD and approval by the Vice President for Finance and Management. Other security measures may be approved by UPD with this form.

Department/Office: Click here to enter text.

Contact Person Name/ Phone number/email: Click here to enter text.

Please describe the area or room(s) to be surveyed and the reason you are requesting security equipment or access restriction. Rooms or areas must fall under the purview of the requesting office.

Click here to enter text.

Type of security hardware/system you would like to request for the space:

Video Camera	Electronic Door Access	Door Combo Lock

Panic Alarm	Burglary Alarm System	Other

Not Sure/Awaiting Recommendation

Specify funding source for implementation of recommended security/video measures:

Click here to enter text.

Please sign and date, then forward to Chief of University Police

Signature Click here to enter text. Title Click here to enter text.

Date Click here to enter text.

THIS AREA FOR UNIVERSITY POLICE USE ONLY

Officer conducting the survey: Click here to enter text.

Signature Click here to enter text. Date: Click here to enter text.

Assessment:

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Notes:

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Recommendations:

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Approved by Chief of University Police	Y N

Signature Click here to enter text. Date Click here to enter text.

If approval includes surveillance camera installation, complete area below:

UPD forward to Vice President for Finance and Management

Approved by Vice President for Finance and Management Y N

Signature: Click here to enter text.

Date Click here to enter text.

Comments: Click here to enter text.

VPFM return to UPD

UPD forward final determination to requesting office

Date Click here to enter text.

Survey Closed Date: Click here to enter text.

Chief of University Police Signature: Click here to enter text.

Last updated 1/8/14.