Fillable Printable Police Incident Report Form - Marion Technical College
Fillable Printable Police Incident Report Form - Marion Technical College
Police Incident Report Form - Marion Technical College
Report Received by __________________________________________________Date _________________________________
Incident Report Form
Use this form to report accidents, injuries, medical situations, or student behaviorincidents. (Incidents involving a crime or
traffic incident should be reported directly to the CampusPublic Safety office.) If possible, the report should be completed
within 24 hours of the event. Submit completed forms to the President’s Office.
INFORMATION ABOUTPERSON INVOLVED IN THE INCIDENT
Full Name
Home Address
StudentEmployeeVisitorVendor
Phone Numbers HomeCell Work
INFORMATION ABOUT THE INCIDENT
Date of IncidentTimePolice NotifiedYesNo
Location of Incident
Description of Incident (what happened, how it happened, factors leading to the event, etc.) Be as specific as possible
(attached additional sheets if necessary)
Were there any witnesses to the incident?YesNo
If yes, attach separate sheet withnames, addresses, and phone numbers.
Was the individual injured? If so, describe the injury (laceration, sprain, etc.), the part of body injured, and any other
information known about the resulting injury(ies).
Was medical treatment provided?YesNoRefused
If yes, where was treatment provided:on siteUrgent CareEmergency RoomOther
REPORTER INFORMATION
Individual Submitting Report (print name)
Signature
Date Report Completed
FOR OFFICE USE ONLY
FOR OFFICE USE ONLY
Document any follow-up action taken after receipt of the incident report.
DateAction TakenBy Whom
