CCC Incident Report

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CCC Incident Report

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CCC Incident Report

CCC Incident Report

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Person Filing Report *

Date and Time of Incident *

Police/Fire Department notified? *

Yes

No

If Yes, Time of notification

If Yes, Officer's Name and RPT#/Badge#:

Security Office notified? *

Yes

No

If Yes, Name/Title:

Client notified? *

Yes

No

If Yes, Name/Title:

Below please list Persons Involved/Witnesses

Witness #1 Name/Position Title

Witness #1 relationship

Employee

Client Employee

Other

Student

Witness #1 Phone number and Organizational Name and Address

Witness #2 Name/Position Title

Witness #2 relationship

Employee

Client Employee

Other

Student

Witness #2 Phone number and Organizational Name and Address

Witness #3 Name/Position Title

Witness #3 relationship

Employee

Client Employee

Other

Student

Witness #3 Phone number and Organizational Name and Address

Witness #4 Name/Position Title

Witness #4 relationship

Employee

Client Employee

Other

Student

Witness #4 Phone number and Organizational Name and Address

Type of Incident/Description of Property/Equipment (if necessary) *

Description of Incident/Injury (WHO, WHAT, WHERE, WHY and HOW. Include all information in detail. *

Officer Name:

Date and Time of Report

Enter your email address *Please enter a valid email address

LOCATION:
Moore Bldg., 1st floor
Phone: 518-593-0777

OFFICE HOURS:
Monday-Thursday
9:00am-5:00pm
Friday
9:00am-4:00pm

STAFF:
Bernard Bullis
Deputy Sheriff

Robert Annis
Deputy Sheriff

Clinton Community College

136 Clinton Point Drive, Plattsburgh, New York 12901 (518)562-4200

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© 2018 Clinton Community College. All Rights Reserved.