Incident Reporting Form

Background Information

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Your full name:

Your position/title:

Your phone number:

Your FLC email address:

Email address must be of a valid format.

Enter your hall here:

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Include your room number

Nature of this report(Required):

This field is required.

Urgency of this report(Required):

This field is required.

Date of incident(Required):

This field is required.

Time of incident:

Location of incident(Required):

This field is required.

Specific location:

Involved Parties

Please list the individuals involved (excluding yourself and other staff members), including name and ID number pasted from the Look-up feature if you have access to it. For non-students, please list a Drivers License number in the block labeled "ID number" if available.

Name or Organization

Select Role

ID Number

DOB (YYYY-MM-DD)

Phone number

Email address

Hall/Address

Questions

How did you become aware of the incident? (someone called the duty phone, doing rounds, emergency, talking during office hours, at a program, etc.)(Required) This field is required.

Please provide a detailed description of the incident/concern using specific concise, objective language (Who, what, where, when, why, and how).(Required) This field is required.

Do you have a follow up plan with these residents? If so, what is it? If not, please note that you will follow up with your RD.(Required) This field is required.

If alcohol was involved, please describe how much and what kind of alcohol was present. Be specific regarding empty bottles, full bottles, etc.(Required) This field is required.

If marijuana was involved, please describe if marijuana was found, marijuana paraphernalia, or odor only Be specific about what you observed(Required) This field is required.

Other staff involved? (Please list out any FLC staff/faculty or community partners that assisted you in this incident).(Required) This field is required.

Supporting Documentation

Photos, video, email, and other supporting documents may be attached below. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

Incident Reporting Form

Background Information

Involved Parties

Questions

Supporting Documentation

Select copy recipients

Submission