subject_line
Incident Report
Today's Date:
*
I am a:
*
Faculty Member
Staff Member
Student
Parent
Other
Reporter Name:
*
Reporter's email
*
Additional Reporter, if any
Additional contact information of reporter (phone number, alternate email, etc.)
*
Program Name, if known:
Date of Incident:
*
Name(s) of those involved in the incident (If possible, please provide full name):
*
Student ID#(s) of those involved in the incident, if known:
Time of Incident:
*
Location of Incident:
*
Did this incident occur on UGA owned/controlled property?
*
Yes
No
Unknown
Others Involved in the Incident:
*
Please check the appropriate box(es) to indicate the nature of the incident:
*
Alcohol/Drugs
Injury/Illness
Theft/Destruction of Property
Lost Property
Arrest of Student
Assault of Student (incl. sexual assault)
Murder/Manslaughter
Arson
Violence Against Women Act (VAWA) (Domestic violence, Stalking, Dating violence)
Harrassment/Discrimination
Natural Disaster/Weather
Transportation Issue
Other, please specify
Other, please specify
Please describe the incident. Be as specific as possible, including all details.
*
0/1000 words
Have any emergency contacts been contacted, for any of the parties involved?
*
Yes
No
I don't know
What actions or steps have been taken so far? Have in country local authorities or U.S. Embassy staff been contacted?
*
0/1000 words
What assistance, if any is needed from UGA?
*
Nothing at this time
Contact reporter at the earliest convenience
Need to access services at UGA
Other
Support Documentation