Guest/Visitor Incident Report (Non-Housing Related)

Background Information

Your full name:

Your position/title:

Your phone number:

Your email address:

Email address must be of a valid format.

Date of incident(Required):

This field is required.

Time of incident:

Location of incident(Required):

This field is required.

Specific location:

Involved Parties

Where possible, please enter all information you are aware of. Do not include yourself or other LMC professional or student staff in this section. Space is available below to include that information.

Name

Pronouns

Role

ID Number

DOB (YYYY-MM-DD)

Phone number

Email address

Address

Incident Report

Please indlude all information available in the description/narrative below:

DESCRIPTION/NARRATIVE: Please provide a detailed description below of the incident using specific, concise, and objective language.(Required) This field is required.

Was Campus Safety involved in this incident?(Required)

None/Not Applicable Yes No

This field is required.

Please list any other LMC professional and staff members who were involved and/or witnessed the incident. If none, please type "None" in the text box.(Required) 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

Incident Report

Supporting Documentation

Submission