Incident Report Form

Date of Incident*

Location of Incident / Event Attended (e.g. Lobby, Jeffrey Siegel Concert, Black Box Theatre)*

Description of Incident*

Would you like to provide your contact information so we can follow up with you?*

Yes No

Name

First Name

Last Name

Phone

IDEA Task Force Chair Section

This section to be completed by chair of IDEA Task Force.

Incident Priority

Critical - immediate follow-up needed and special task force meeting called Important - report to task force via email, no special meeting needed Normal - report to task force in monthly meeting

Notes from IDEA Task Force Chair

IDEA Task Force Section

This section to be completed at meeting of IDEA Task Force.

Date of Task Force Discussion

Notes from Task Force Meeting / Recommended Actions

Which AC staff members will be notified of this discussion?

Which AC staff members will follow up on this incident?

Staff Follow-Up

Assigned staff will complete this section.

Name of Staff Completing this Section

How was this incident addressed?

Is any additional action needed?