Incident Reporting Form

Reporter Information

This is information about yourself so we can contact you if we need more information.

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Your full name:

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Your position/title:

Your phone number:

Your email address:

Nature of this report(Required):

This field is required.

Date of incident(Required):

This field is required.

Time of incident:

Location of incident(Required):

This field is required.

Specific location:

Involved Parties

Please list the individuals involved (excluding yourself), including 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 Organization

Select Role

JSU ID Number

Phone number

Email address

Questions

Please utilize detail to describe the incident in question, whether it be an alleged violation of a policy or any behavior that is abnormal or concerning.

Please provide a detailed description of the incident/concern using specific concise, objective language (Who, what, where, when, why, and how).(Required) This field is required.

Were there other internal or external entities contacted during this incident? (for example, counseling services, UPD, EMS, Parents, etc.)

Counseling and Disability support services University Police EMS Parents of those involved Residence Life Staff Jacksonville Police Title IX Coordinator Student Health Facilities

You must make at least one selection.

Supporting Documentation

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

Reporter Information

Involved Parties

Questions

Supporting Documentation

Submission