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Incident Reporting Form

If this incident requires immediate attention, please contact Campus Safety (x7770 / 616-395-7770) or Ottawa County Central Dispatch (911).

If the situation that you are reporting is an incident of discrimination, harassment, or assault (based on ability, age, ethnicity, gender, gender expression, race, sex or sexual orientation), please complete a Discrimination and Harassment Reporting Form.

Background Information

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Your full name:

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Or, you may write Anonymous

Your position/title:

Your phone number:

Your email address:

Email address must be of a valid format.

Your physical address:

Type 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 the individuals involved (excluding yourself), including as many of the listed fields as you can provide. For non-students, please list an SSN or Drivers License number in the block labeled SID (Student ID #) if available.

Name or Organization

Select Gender or List Organization Name

Select Role

ID Number

DOB (YYYY-MM-DD)

Phone number

Email address

Hall/Address

Questions

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