If an incident occurs, proper documentation is crucial to follow-up. This incident report form was developed by Allison B. Peters in 2012 for use for campus events. An online version was also developed for on the go access.

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