Grambling State University

HOUSING INCIDENT REPORT

Grambling State University
Division of Finance and Adminstration
Office of Residential Life

GSU Box 4309
Grambling, LA. 71245
Telephone: (318) 274-2504/Fax: (318) 274-4004

HOUSING INCIDENT REPORT


Name of Individual Submitting Report:
Title (if any):		Office/College/Dept:
Home/Office Phone Number:		Cellphone Number:
Address/Building:	Room:	City/State/Zip:
Incident Date:	Time:	Location:

Name(s) of individual, student(s) or student organization(s) involved in alleged violation	Student ID #	Telephone/Cell Number	Campus Address

Name(s) of witness(es)	Student ID #	Telephone/Cell Number	Please indicate status of witness:
			Grambling State Faculty/Staff Grambling State Student
			Grambling State Faculty/Staff Grambling State Student
			Grambling State Faculty/Staff Grambling State Student

Summary of Incident
Description of Incident (include only factual information- who, what, when, where, how, etc.):

E-mail Address: