REPORTER INFORMATION

Person Completing Report
Email Address
Incident Date			Time:		a.m. p.m.
Location:

PERSON(S) ALLEGEDLY INVOLVED

Name	Date of Birth	Building/Room #	Cell Phone	Alleged Involvement (see codes below)

INVOLVEMENT CODES

Abuse (AB) Alcohol (AL) Appliances (AP) Disorderly Conduct (DC) Drugs (DG) Environmental Safety (ES) Failure to Comply (FC) Fire Safety (FS) Firearms/Weapons (FW) Guests/Visitor (GT) Harassment (HA) Noise (NS) Pets (PE) Physical Assault (PA)

Room Modification (RM) Safety/Security (SY) Sexual Assault (SA) Solicitation (SO) Theft (TH) Tobacco Products (TP) Vandalism (VN) Additional Codes: Alcohol Transport (AT) Medical (ME) Medical Transport (MT) Mental Health (MH) Mental Health Transport (HT) Victim (VT) Witness (WT) Other (OT) please specify

DESCRIPTION OF THE INCIDENT

This section should be completed by the person who files the complaint or those who witnessed the incident. Describe the incident with as much detail as possible. Include only the facts of the incident as observed or reported - not your opinion. Describe your role and actions in third person. You may attach additional pages, if necessary.

STATEMENT

By submitting this report to Defiance College I certify that the information given on this application is complete and accurate to the best of my knowledge.