DRAFT- FASA Incident Reporting Form--DRAFT

Background Information

Enable additional features by logging in.

Your full name:

Learn more

Or, you may write Anonymous

Your position/title:

Your phone number:

Learn more

Please include extension if applicable.

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:

MAU 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 including the following: and role of the Claimant, the name and role of the Respondent, (if known), and the names and roles of any witnesses or bystanders who may have witnessed the behavior. If you do not know the name of the Respondent, please type, Unknown Respondent in the name field.

Definition of Roles:

Claimant: The individual who experienced the alleged behavior.
Respondent: The individual who engaged in the alleged behavior.
Witness: An individual who has a first-hand account of the alleged behavior.
Bystander: An individual who has a first-hand account of the alleged behavior and who tried to intervene to stop the alleged behavior.

Full Name Of Respondent or Claimant

Select Role

ID Number

Phone number

Email address

Hall/Address

Questions

Please provide a detailed description of the incident/concern using specific concise, objective language (Who, what, where, when, why, and how).(Required) This field is required.

Was law enforcement notified?(Required) This field is required.

If law enforcement was notified, please select the agency that responded? (Check all that apply)

Michigan State University Police Department East Lansing Police Department Lansing Police Department Ingham County Sheriff's Office Other law enforcement department

You must make at least one selection.

If yes, the University Police were notified, is there additional information we should have? (Police officer's name, police report number, etc.)? If so please provide that below. 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

Shannon Kemp

Kathy Lewless

Melissa Sortman

Jennie Yelvington

Kara Yermak

Email me a copy of this report

Background Information

Involved Parties

Questions

Supporting Documentation

Select copy recipients

Submission