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Incident Reporting Form

Please note that submissions using this form may not be reviewed outside of normal business hours. If there is immediate risk to health or safety, please contact University of Houston Police Department at 713-743-3333.

Items marked with a * are required fields.

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.

Urgency 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-students, please list an SSN or Drivers License number in the block labeled SID if available.

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.

Did police respond?(Required)

Yes No

This field is required.

Hospital transport occurred(Required)

Yes No

This field is required.

Was emergency contact notified?(Required)

Yes No N/A

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.

Select copy recipients

Email me a copy of this report

Background Information

Involved Parties

Questions

Supporting Documentation

Select copy recipients

Submission