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For an immediate response please contact the appropriate parties, in addition to filling out this form. Please see:
* Required fields are marked with an asterisk.
Location of incident/complaint*
Date* (mm/dd/yy)
Time*
Name of person filing report*
E-mail*
Unit*
Phone number*
Select the type of Incident
[ select type of Criminal Behavior ] Theft-Personal Items Theft-Library Property Vandalism-Damaged Property Assault Other
Description of Incident/Accident/Complaint* (Please provide as much information as possible) PLEASE DO NOT INCLUDE ANY INFORMATION THAT COULD IDENTIFY THE VICTIM(S).
Subject Affiliation: Staff Student Unknown Other
Subject Description:
Race
Sex
Build
Height
Weight
Hair
Eyes
Clothing
Description of Property/Equipment (Include brand, model, color, year, license or serial #)
Description of Injuries and Assistance Rendered
Was the Injured Person Transported to a Hospital? Yes No
Name of Hospital
Police Department Notified: Yes No Injured person refused to call police
Police Report number
Officer's Name/Badge number
Fire Department Called: Yes No
Send a copy of this report to your supervisor E-mail Address of your supervisor
Form output will also be e-mailed to libsecurity@lists.berkeley.edu.
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