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CCC Incident Report
If you see this don't fill out this input box.
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
Click to Submit Incident Form
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LOCATION:
Moore Bldg., 1st floor
Phone: 518-593-0777
OFFICE HOURS
STAFF:
Jeff Martin
Deputy Sheriff
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