Smoke & Tobacco-Free Incident Reporting Form

Reporter Information

Please provide your contact information so that we may follow up with you if needed.

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Your name:

Your position/title:

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If you are a student, please type

Your phone number:

Your email address:

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Nature of this report(Required):

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Please indicate whether this report is regarding Faculty/Staff, or Student behavior.

Date of incident(Required):

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Time of incident:

Location of incident(Required):

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Specific location:

Involved Parties

Please list all available information regarding the individual(s) involved. Be sure to include their Stetson ID number when possible.

First and Last Name

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Select Role

ID Number

Phone number

Email address

Questions

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

Was the individual approached regarding their behavior?(Required)

Yes No

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If yes, please describe the nature of the intervention and the individual's reaction/response. This field is required.

Supporting Documentation

Photos, video, email, and other supporting documents may be attached below. 5GB maximum total size.
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Reporter Information

Involved Parties

Questions

Supporting Documentation

Submission