Western Illinois University: Macomb Campus

Type of Incident (check all that apply):*

Hazing (See Hazing Form) Injury (requires medical attention) Harassment
Fighting Minor Injury Sexual Assault
Alcohol/Drug Violation Vandalism Theft
Other (please specify)

Name:*

E-mail address:*

Phone Number:* (XXX-XXX-XXXX)

Date:*

Time:*

Location of Incident:*

Description of Incident:*

Names and Chapters of Individuals Involved:*

Were Police notified?:*
Yes No

Names of Officers Involved:

Case Number: