Incident Report Form

Residence Life Incident Report Form
Complete this form to report an incident occurring in the residence halls.

Required information is in bold red.

Reporter Information (the person completing this form)
Name (First and Last):
ID:  
Building/Room:
Phone Number:  
Email:

Please List Other Respondents to Incident
Other Respondents to Incident:  

Accused Student(s) Information
Name:
ID:  
Building/Room:
Phone Number:  
Birth Date:
   
Name:

ID:  

Building/Room:  

Phone Number:  

Birth Date:

   
Name:

ID: 

Building/Room: 

Phone Number: 

Birth Date:
Please list additional students involved.
 

Additional Information
                                                                                                 Day of Incident:
Date of Incident:  [None] Select a Date Delete the Date
Time of Incident:  (indicate a.m. or p.m.)
Location of incident:   

 Location details:
Please list the residence hall and room number where the incident occurred; OR describe the incident location as best you can, for example McNiff men's locker room: 
Circumstances:  
Campus Safety personnel involved?:
                                  
If YES, who?
(name and badge numbers if known)
Police called?:
                                   

EMS/Ambulance called? 
                                   

Head Resident notified?:
                                   

Area Coordinator notified?:
                                   

Assistant Director notified?:
                                   


This form will be submitted to the Office of Residence Life and shared with other departments (Office of Student Conduct, Health and Counseling Center, Campus Safety, etc) as necessary.

After submission, an email confirmation will be sent to the email address provided in the form above. If you do not receive a confirmation, please contact the Office of Residence Life at reslife@ut.edu.