Incident Report

Background Information

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Your full name:

Your position/title:

Your cell phone number:

Your email address:

Email address must be of a valid format.

Your GC ID number or SID:

Nature of this report(Required):

This field is required.

Urgency of this report(Required):

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Date of incident(Required):

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Time of incident:

Location of incident(Required):

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Location (Room#, Street Name):

Involved Parties

Please list the individuals involved (do not include yourself). Include as many of the listed fields as you can provide. For non-students, please list an SSN or Drivers License number in the block labeled SID (Student ID #) if available.

Name or Student Group

Select Gender or Student Group

Select Role

GCID Number (or SNN or Driver's License)

DOB (YYYY-MM-DD)

Individual's Cell Phone number

Individual's Email address

Individual's Hall/Room#, Local Address, or Other Address of Residence

Details

Please check the appropriate checkboxes that are relevant to this incident.

STUDENT GROUP VIOLATIONS

RULE 300. DRUG ABUSE

RULE 301. EVENT REGISTRATION

RULE 302. LOCAL & STATE LAWS

RULE 303. NAT'L ORGANIZATION POLICIES

RULE 304. NOISE

RULE 305. HAZING

You must make at least one selection.

INFORMATIONAL

Intramural Sports Injury

Accident or Other Injury

Medical Issue

Study Abroad Concern

Complaint

You must make at least one selection.

Please provide a detailed description of the incident using specific concise, objective language (who, what, where, when, why, and how). For "accident and injury" reports, please describe the injury including the location of the bodily injury.(Required) This field is required.

Select any of the following that apply:

GC Police was involved

Milledgeville PD was involved

Baldwin County Sheriff's Office was involved

Georgia State Patrol was involved

Baldwin County Fire Dept was involved

Arrest was made

EMS transport

EMS called - refused transport

EMS called - no transport needed

You must make at least one selection.

If involved, please provide GC Public Safety Officers names: This field is required.

SKIP THIS SECTION: RESIDENCE LIFE STAFF ONLY Check all that apply.

CD on Duty called

AC on Duty called

Kevin Blanch (A,B,N,S)

Desaree Murden (F,W,P)

Lori Burns (DIR)

You must make at least one selection.

Photos, video, email, and other supporting documents may be attached below. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

Email me a copy of this report

Background Information

Involved Parties

Details

Submission