Campus Safety Incident Report

Campus Safety > Crime & Safety > Campus Safety Incident Report

Report Filed by: *
Position of Reporter:
Date of Incident: *
Time of Incident:
Type of Incident: *
Location: *
If "Other", please explain:
Room/Area:
Individuals Involved
Any additional Student, Non-Student or Staff Info that does not fit here may be included at the end of the narrative part of the report
Students
Student:
Name:
Building/Room:
Box No.:
Additional Student:
Name:
Building/Room:
Box No.:
Additional Student:
Name:
Building/Room:
Box No.:
Additional Student:
Name:
Building/Room:
Box No.:
Additional Student:
Name:
Building/Room:
Box No.:
Non-Students
Non-Student:
Name:
Address:
Phone No.:
Additional Non-Student:
Name:
Address:
Phone No.:
Additional Non-Student:
Name:
Address:
Phone No.:
Faculty/Staff
Faculty/Staff:
Name:
Department:
Phone No.:
Additional Faculty/Staff:
Name:
Department:
Phone No.:
Additional Faculty/Staff:
Name:
Department:
Phone No.:
Check all that apply:
Staff on call notified: *		Yes No
Police Notified: *		Yes No Unknown
Ambulance/Fire Department called: *		Yes No Unknown
Individual(s) informed that report would be written: *		Yes No
Property Damaged: *		Yes No Unknown
Alcohol or other drugs involved: *		Yes No Unknown
Facility Service Work Request filed: *		Yes No Unknown
Additional Documentation:
If you have more than one file to submit for this report you may submit them directly to mwilliamson@cornellcollege.edu
Submit File:
Incident Narrative:
Relevant Information: What happened? How did it happen? Are there any explanations as to why this occurred?: *

I verify that the above statements are correct: *		Yes

* Required Field