Incident Report Form

Background Information

Enable additional features by logging in.

Your Full Name:

Your Position/Title:

Your Phone Number:

Your Email Address:

Email address must be of a valid format.

Your Physical Address:

Nature of Report(Required):

This field is required.

Date of Incident(Required):

This field is required.

Time of Incident:

Location of Incident(Required):

This field is required.

Specific Location:

Involved Parties

Please list all parties involved (excluding yourself) and provide as much information as possible in the demographic fields. If you do not have access to the demographic information, please continue to submit the report; the information will be researched once the report is received.

For an individual who is not a member of the University community, please list a drivers license number in the field labeled ID Number (if available). If the individual is a student at another college or university, please provide the name of that institution in the field labeled Residence Hall/Local Address.

Roles in which the parties may be involved include the following:

Accused: member of the University community who may have violated University policy
Victim: alleged victim or individual who may be impacted by an incident
Witness: individual (excluding yourself) who observed the alleged behavior and can provide additional information
Involved Party: member of the University community who is involved in an incident and does not fall into the categories of Accused, Victim, or Witness
Other: individual who is not a member of the University community

Name or Organization

Gender

Role

ID Number (No Dashes)

Date of Birth

Phone Number

Email Address

Residence Hall/Local Address

Description

Please provide a detailed description using specific, concise, objective language. Describe, in as much detail as possible, the specific behaviors observed, including words, phrases, and actions, and dates and times. If the involved party used profanity, made threats, or spoke of harming self or others, indicate specific words and phrases used. If the involved party was loud or disruptive, indicate any behaviors associated with the disruption, and describe any injury or damage to individuals or property. Include names of University personnel you contacted and actions taken, if any. For readability, identify individuals in the description by last name.

Please provide a detailed description using specific, concise, objective language.(Required) This field is required.

Select any of the following that apply:

Involved Party Requests Confidentiality Police Involved Arrested/Booked Medical Response - No Transport Needed Medical Response - Transport Refused Medical Transport

You must make at least one selection.

If other University staff responded (e.g., PPS, HRL Staff), please list their names: This field is required.

Will other University staff who responded be submitting an incident report? This field is required.

Supporting Documentation

Photos, video, email, and other supporting documents may be attached below. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

Email me a copy of this report

Background Information

Involved Parties

Description

Supporting Documentation

Submission