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Campus Emergency Response Team (CERT)
Incident Reporting Form

Date of Incident
 Time of Incident
(Please indicate AM or PM)
Location of Incident
Your Name
You Are A
Student

Staff		 Faculty

Other
Your ID Number
 Your Email Address
Your Contact Information
Name of Person Being Reported
The Person Being Reported Is A
Student

Staff		 Faculty

Other
The Person Being Reported's Contact Information
Witness('s) Name(s) and Contact Information
Please provide a detailed description of the incident and any other individuals involved. Describe specific behavior exhibited as well as statements made by the person being reported. Also, please provide any supporting documentation associated with the incident at the request of CERT. Once this form is submitted, you will receive an e-mail confirmation and a member of CERT will contact you.
**Confidentiality Disclaimer**
The Campus Emergency Response Team (CERT) will make every effort to keep all information confidential. However, please be aware that although maintaining confidentiality is of the utmost importance, it must also be balanced with our mandate and responsibility to protect the safety of our entire campus community.