Grambling State University
Division of Student Affairs
Office of Student Judicial Affairs

GSU Box 4309
Grambling, LA. 71245
Telephone: (318) 274-6149/Fax: (318) 274-3297

INCIDENT REPORT

Name of Individual Submitting Report:

Title (if any): Office/College/Dept:

Home/Office Phone Number: Cell phone Number:

Address: 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 individual, student(s) or
student organization(s) involved in alleged violation

Student ID #

Telephone/Cell Number

Campus Address 		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:
Select...

Name(s) of witness(es)

Student ID #

Telephone/Cell Number:

Please indicate status of witness:
Select... 		Name(s) of witness(es)

Student ID #

Telephone/Cell Number:

Please indicate status of witness:
Select...

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

Submitted by: Date:

 

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