Incident Report Form

Background Information

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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 this 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 the individuals involved (EXCLUDING yourself), including as many of the listed fields as you can provide. For non-affiliate persons, please list a Drivers License number in the block labeled SID if available. If you have listed your information as the person submitting the report, you DO NOT need to include duplicate information. Note:"Respondent" refers to the individual about whom you have concerns. If Champlain College is the student of concern, please use Datatel number 0000000.

Full Name or Organization

Select Gender

Select Role

ID Number

DOB (YYYY-MM-DD)

Phone number

Email address

Hall/Address

Questions

Please provide a detailed description of the incident/concern using specific concise, objective language. This field is required.

If this report involves you, how would you like us to follow up with you? This field is required.

If you are submitting this report on behalf of others, are they aware? 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

Questions

Supporting Documentation

Submission