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INCIDENT REPORT

Student Life Office

Lock Haven University of Pennsylvania

 

 

Date Filed     

 

 

Resident Assistant/Staff: Last/First Name

Campus Address

Phone

1.       

 

 

2.       

 

 

3.       

 

 

 

Person(s) Involved: Last/First Name

Address

  Phone

Student ID #

Date of Birth

1.       

 

 

 

 

 

2.       

 

 

 

 

3.       

 

 

 

 

4.       

 

 

 

 

5.       

 

 

 

 

6.       

 

 

 

 

7.       

 

 

 

 

8.       

 

 

 

 

 

Date of Incident 

 

Time of Incident 

 

Location of Incident 

 

 

University Violation(s)

1.       

 

2.       

 

3.

 

Law Enforcement officer(s) Involved: (circle one)

 

None               McCauly          Bissman            Fye      Johnson                       

 

Grenninger        Getz     Hall      Morgret   Bealer               
 

 

Description of Incident: