Campus Safety Incident Report
To be completed by Complainant
Date (mm/dd/yyy)
Name
Type of Incident: (check applicable space)
Theft
Injury/Accident
Illness
Blood Born Pathogen
Type of Complaint
Student
Faculty/Staff
Other
If Other
Loaction (Building & Room)
Date of Incident (mm/dd/yyyy)
Day of Week
Time (hh:mm AM/PM)
Witness(es) to Incident
To be completed by University Official
Name & Position of University Official
Were any of the following called:
Police
Paramedics
Fire
Other
If Other
Please give complete details of incident (example: items stolen, suspects, specific nature of injury,etc.)
Office Use Only
Clearly Recordable
Yes
No
White: SLO - Yellow: OJA - Pink: CS
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