Incident Reporting Form

Background Information

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Your full name:

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Or, you may write Anonymous

Your position or title:

Your phone number:

Your email address:

Email address must be of a valid format.

Your physical address:

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 all of the individuals involved (excluding yourself), including the accused (Respondent), victim (Complainant), and witnesses. Please fill-in as many of the listed fields for the listed individual as you are aware. For non-students, please list an Social Security Number (SSN) or State-issued Drivers License/Identification Card (OLN) number in the block labeled SID (UTC ID) if it is known.

Name or Organization

Select Gender

Select Role

UTC ID

DOB (YYYY-MM-DD)

Phone number

Email address

Residence Hall / Local Address

Questions

Please provide a detailed description of the incident/concern using specific, concise and objective language (i.e. Who, What, Where, When, Why, and How). This field is required.

Please indicate if additional agencies, offices, or departments were notified and/or present related to this incident:

UTC Police Department Other Police Department (provide agency and report # below) EMS/Ambulance Fire Department Counseling Center Survivor Advocacy Services Other

You must make at least one selection.

Please provide the case/incident report number for UTC Police Department, Other Police Department, EMS/Ambulance, or Fire Department, if known. This field is required.

Please provide the name of any UTC faculty or staff member(s) notified and/or present from additional agencies, offices, or departments, if known. 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.

Background Information

Involved Parties

Questions

Supporting Documentation

Submission