Time and Place:
1. Where did this incident occur: On campus Off campus
    Specific location: 
2. Date of incident: / / 
3. Time of incident: A.M. P.M.
4. Name of person submitting this report: 
5. Position title of person submitting this report: 
6. When did you become aware of this incident? / / 

Who is Involved in this Incident?
1. Name: 
Department: 
Relationship/Position title: 

2. Name: 
Department: 
Relationship/Position title: 

3. Name: 
Department: 
Relationship/Position title: 

4. Name: 
Department: 
Relationship/Position title: 

Summary of Incident:
Additional comments that you feel are pertinent to an investigation of this incident can be made on a supplemental sheet (Who, what, when, why)

NOTE: Only the first 21 lines will print out for each text box below (i.e., if your entire response does not appear on screen without scrolling the text box up or down, lines 22, 23, etc will not print out).  If your response will be longer than the space allowed, please continue your response on another sheet of paper, note this in the text box, and fax it with the rest of the form.

Witness(es):
1. Name: 
Department: 
Relationship/Position title: 

2. Name: 
Department: 
Relationship/Position title: 

3. Name: 
Department: 
Relationship/Position title: 

4. Name: 
Department: 
Relationship/Position title: 

Required Notification:
1. Appropriate department head notified of mobilization of Risk Assessment Team:
Name: 
Department: 
Date notified: / / 

2. Human Resources divisional office notified:
Name: 
Date notified: / / 

3. Security notified (when appropriate):
Name: 
Date notified: / / 

Signature: _____________________________________

Date:        _____________________________________