Campus Community Safety Report Form

Your Information

Please complete the following information as the filer of the report. There will be a section further down to provide information about any person(s) involved.

Your full name:

Your position/title:

Learn more

(Ex. Student, Faculty/Staff, Parent, etc.)

Your phone number:

Learn more

(Please include area code)

Email Address:

Email address must be of a valid format.

Learn more

(Please use Western email address if student or employee)

Type of Incident(Required):

This field is required.

Learn more

Please choose the category that best describes the type of incident

Date of incident(Required):

This field is required.

Time of incident:

Location of incident(Required):

This field is required.

Specific location, if relevant:

Learn more

(Ex. Room C131, 1st Floor Restroom, etc.)

Person(s)/Parties Involved

Please list all individual(s) involved in the incident, including the alleged violator, victim, or any witnesses/persons who have direct knowledge of the situation. Please include as many of the listed fields as you can provide for each individual. For non-students, please list last name, first name all together in the student ID field. (ex. John Smith would be SMITHJOHN)

Full Name (First, M.I., Last) or Organization

Gender Identity

Role in incident

ID Number (ex. 001234567)

DOB (YYYY-MM-DD)

Phone number with area code

Western email address

Incident Details

Please answer the following questions about the incident:

Please provide a detailed description of the incident/concern using specific objective, detailed and fact-based information and avoid stereotypes, labels, or opinions.(Required) This field is required.

Alcohol or drug involvement?(Required)

Yes No Unknown

You must make at least one selection.

Agencies notified (check all that apply):

Campus Security Local law enforcement Ambulance Fire Other

You must make at least one selection.

Supporting Documentation

Please attach any supporting documentation (ex. photos, police reports, video footage, etc.) 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

Email me a copy of this report

Your Information

Person(s)/Parties Involved

Incident Details

Supporting Documentation

Submission