Incident Report Form

Date of Report:

mm/dd/yy

Report Submitted by:

Unit name:

Date & Time of Incident:

Place of Incident:

Description:

Please Describe the incident in detail, including your response.

Nature of Incident:

Elevator

Fire/Smoke Actual

Fire/Smoke Alarm

Medical

Power Failure

Problem Patron

Theft

Safety

Other

Could this have been prevented? (optional):

If this incident could have been prevented by action of the Library or the campus authorities, suggest preventative action to be taken.

Your Email:

If you would like to recieve a copy of this form, please enter your email address including @uwec.edu.