Incident Report Form

Use this form to report incidents and issues that occur on campus or that affect members of the campus community. If you or anyone you know has been involved in an incident that you feel the college should be made aware of, please fill out this form to the best of your ability.

Contact the Office of Student Life with any questions at 419-783-2437.

If you need immediate assistance, please call Campus Safety at 419-783-2625. For emergencies, call 911 first, then Campus Safety.

If you see this don't fill out this input box.

PERSON COMPLETING THE REPORT:

Reporter's name: *

Email address: *

Incident date & time: *

Incident location: *

PERSON(S) ALLEGEDLY INVOLVED:
For each person, please supply name, date of birth, building/room #, and cell number.

Name(s) of person(s) allegedly involved: *

ID number of person(s) allegedly involved:

Building/room # of person(s) allegedly involved:

Cell number(s) of person(s) allegedly involved:

Describe what happened: *The description 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.

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.

Incident Report Form

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