The document details an incident report form used for documenting various types of incidents, including accidents, assaults, and policy violations. It requires general information about the incident, individuals involved, and the nature of the response. The form also includes sections for follow-up and additional notes if necessary.

1. IncidentReport 1
Incident Report Form
General Information
Day of Incident Sun Mon Tues Wed Thus Fri Sat
Date of Incident Time of Incident AM/ PM
Locationof Incident
Name of Eventor Brief
Description
Staff Reporting Incident
Date Prepared Time Prepared AM/ PM
Name (last,first,MI) Phone # Email Address
Position Signature
Person/Group Involved (Primary)
Name (last,first,MI) or group name
Phone # Email Address
Affiliation □ Student □ StudentStaff □ Faculty/Staff □ Guest
□ Other_______________________
Involvement □ Accused □ Victim □ Witness
Person/Group Involved
Name (last,first,MI) or group name
Phone # Email Address
Affiliation □ Student □ StudentStaff □ Faculty/Staff □ Guest
□ Other_______________________
Involvement □ Accused □ Victim □ Witness
Person/Group Involved
Name (last,first,MI) or group name
Phone # Email Address
Affiliation □ Student □ StudentStaff □ Faculty/Staff □ Guest
□ Other_______________________
Involvement □ Accused □ Victim □ Witness
Add additionalindividualsinvolved on anothercopy of this pageif necessary

2. IncidentReport 2

3. IncidentReport 3
Incident Information
Type of Incident Classification of Incident
□ Accident(physical)
□ Accident(vehicular)
□ Assault/Fight
□ Complaint
□ PolicyViolation
□ Theft
□ Threat
□ PropertyDamage / Vandalism
□ Other:__________________________________
□ Eventor facility-related
□ Interpersonal incident/conflict
□ Minor injuryor illness
□ Seriousinjuryorillness
□ Other:__________________________________
Describe how the incidentoccurred usingas many detailsas possible (usea separatesheetif needed).
Describe what thepersoninvolvedwas doing when theincident happened
Describe the injuries or damage / any first aid/medicalassistancethatwas given, and by whom
Response
□ Reportonly(noresponse)
□ Care notneeded
□ Victimrefusal of care
□ Medical attentionon-site
□ Referral HealthServiceson-campus
□Referral tohealthservicesoff-campus
□EMS transport
□ PD/securitysummoned
Officer’sName &Agency:
___________________________
□ Campus □ City □ Third-partysecurity
□ Police reportfiled
Report#: ___________________
Office Use Only
Date ReportReceived Time ReportReceived AM/ PM
Follow-Up