This form is typically used to report incidents where police response is required.
Note: Required fields are marked with an *
1. *Was there police involvement? YesNo If there was police involvement, list the name of the responding officer and the Police Report #:
2. *Type of incident (e.g. injury, harassment, trespassing, fire alarm, medical response, etc.)
3. *Date of incident (Month/Day/Year)
4. *Time of incident
5. *Location of incident (Library, floor, service desk, room/carrel number, etc.)
6. *Description of incident
7. Individuals involved in incident (List all persons involved in the incident, including name, UID - if applicable, addresses and phone numbers.)
8. Was there an apparent injury? YesNo If there was an apparent personal injury, please list the name of the person injured, the type of injury, and any medical response (e.g., EMT response, transported to hospital, taken to Health Center, etc.)
9. What actions, if any, were taken by Library staff in response to the incident (e.g., called police, etc.).
10. Please provide any other details you feel necessary regarding this incident.
*Last Name: *First Name:
*E-mail address (where you will can be contacted if additional information is needed): e.g., smith@umd.edu, ann@hotmail.com
Telephone:
*Status: Library Faculty Library Staff Graduate Assistant Student Assistant Other (please state):
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