Incident Report Form - University Recreation

Name of member/victim: *

Member's phone number: *

Member's email address: *

Type of Member: *

Student Faculty/staff Alumni Community Guest

Date of birth: *

University ID#: *

Date of incident: *

Time of incident: *

Where did incident occur: *

Name of person completing form: *

Nature of incident (i.e., theft, misconduct): *

During what kind of activity did this incident occur? *

Sport Club Intramural Facility Rental Informal Recreation Well-being Center Other

If other, please specify:

How did the incident occur? *

Action taken: *

Were University police called? *

Yes No

Was an ambulance called? *

Yes No

Was the On-Duty Director called? *

Yes No

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