Incident Report Incident Report Incidents and accidents may involve minor to major physical injuries of participants and/or program staff, behavioral issues, hospital/doctor visits, or over-the-counter medication disbursement. A person having cause to believe that a minor’s physical or mental health or welfare has been adversely affected by abuse, neglect, or other maltreatment by any person shall immediately make a report to local law enforcement. Please submit the following information within 24 hours of any incident involving injury to or affecting the health or safety of a participant. [1] [1] In addition to submitting this incident report, immediately call Sgt. Rodger Paxton in the University Police Department at 979-845-8895 (office), 979-574-6179 (cell) for any incident involving physical violence causing substantial injury (assault), weapons used in the commission of a crime, rape, fondling, date rape drugs or other substances used to facilitate a crime, or predatory behavior. The call is to initiate Clery daily crime log disclosure and crime alert evaluation and will not generate a police response. Program/Event Name: * Session Name (if applicable): Host Organization/Department: * Report Date/Time: * Date/Time of Incident: * Remember: Incident Reports must be submitted to University Youth Programs within 24 hours of the incident's occurrence. Location of Incident: * Detailed Description of Incident: * Does the Nature of Report include any of the following:(For Clery and Title IX Purposes)Dating/domestic violence, Sexual Assault (Rape, Fondling, Incest, Statutory), Sexual Exploitation, Sexual Harassment, Stalking, Discrimination, Harassment, Retaliation Murder or manslaughter, Robbery, Burglary, Theft, Aggravated Assault, Hate Crimes, Arson, Motor Vehicle Theft, Alcohol/Drug/Weapons Law Violation, or any Law Violation * Yes No Unknown/Unsure Root Cause of Incident: Corrective Action(s) Suggested: Did Police respond? * Yes No Officer Responding: * Please indicate N/A if the incident did not involve law enforcement. Incident Report Number: Did anyone receive treatment at a medical facility? * Yes No Where? Please indicate N/A if the incident did not involve treatment at a medical facility. Transport Provided By: Was an insurance claim report filed? * Yes No Are you a mandatory reporter [2]? Yes No Unknown/Unsure [2] (An employee of Texas A&M who is required to report alleged discrimination, harassment, or retaliation) Reporting Party Name: The reporting party is the individual filing the incident report. Reporting Party Phone Number: Reporting Party Email: Party 1 Name: * Please provide the information for the involved parties of the incident. Party 1 Address: * Party 1 Phone Number: * Party 1 Parent/Legal Guardian: * Is Party 1 a Complainant/Victim or Respondent/Suspect? * Complainant (person who experienced misconduct)Respondent (person who allegedly engaged in misconduct)Neither Party 1 Status * StudentFacultyStaffThird PartyUnknown/Unsure Party 2 Name: Party 2 Address: Party 2 Phone Number: Party 2 Parent/Legal Guardian: Is Party 2 a Complainant/Victim or Respondent/Suspect? * NeitherComplainant (person who experienced misconduct)Respondent (person who allegedly engaged in misconduct) Party 2 Status * Unknown/UnsureStudentFacultyStaffThird Party Witness 1 Name: Please provide the information for any witnesses to the incident, if different from the reporting party. Witness 1 Phone Number: Witness 1 Address: Witness 2 Name: Witness 2 Phone Number: Witness 2 Address: Web Copy of Files (if applicable) If you are human, leave this field blank. Submit
