Campus Incident Report

Campus Incident Report Form
Please fill out the form below to report an incident to the Campus Security Department.
DO NOT USE THIS FORM FOR REPORTING OF EMERGENCY SITUATIONS, INCIDENTS THAT ARE IN PROGRESS, OR REQUIRE IMMEDIATE ATTENTION.

IF YOU NEED IMMEDIATE SERVICE OR HAVE AN EMERGENCY, PLEASE CONTACT CAMPUS SECURITY AT EXTENSION 777.

Complete the form and submit

Today's Date: (mm/dd/yyyy)
Incident Date: (mm/dd/yyyy)
Incident Time: (hh:mm)
Incident Location:
Type of Incident:	- Auto Accident Behavioral Criminal Complaint Damage of Property Ill Person/Injured Person Other
If other, please describe:
Your Connection to CCC:	FT Employee PT Employee
Job Title:
Department:
	FT Student PT Student
	Continuing Ed Student
	University Partner Student
	Visitor
Your Involvement with Incident:	- Complaint Witness Victim Other
If other, please describe:
Please be as detailed as possible, inlcuding all relevant information
Description of Incident:
Others involved in incident, including witnesses
Full Name:
Phone Number:
Involvement:
Email:
Full Name:
Phone Number:
Involvement:
Email:
Full Name:
Phone Number:
Involvement:
Email:
Local Police Notification:	Yes No
If Yes, What Departmet?
I have read this statement and I certify that the facts contained herein are true and correct. Dishonest reports and/or false claims may result in potential disciplinary action against you by Cumberland County College.
First Name:
Last Name:
Address:
City:
State:
Zip Code:
Home Phone:
Cell Phone:
Email:
If you wish to report this incident in person or by telephone, please contact the Information Desk/Campus Security, located in the lobby of the Student Center Building, Mondays throough Sundays, 7AM to 11PM, or call (856)691-8600 ext. 777.
Your IP Address is:38.107.179.206