Common Incidents
- Domestic violence
- Sexual assault
- Burglary
- Motor vehicle theft
- Vandalism
- Traffic accidents, including hit-and-run and DUI
Essential Information
The form should record the following information so it can be relayed to law enforcement:
- Date, time, and location of the incident
- Names and addresses of the parties involved*
- Detailed description of what occurred
- List of any injuries, damages, or stolen property
*It’s helpful to include some form of identification, such as a driver’s license or passport number, to ensure each party involved in the incident is correctly identified.
Sample
Full Name: [FILER NAME] Role in Incident: [ROLE (E.G., VICTIM)]
Signature: Date: [MM/DD/YYYY]
INCIDENT DETAILS
Location: [INCIDENT LOCATION]
Incident Type: ☐ Theft ☐ Vandalism ☐ Assult ☐ Traffic Accident ☐ Other: [INCIDENT TYPE]
Describe the Incident: [DESCRIBE INCIDENT]
PARTIES INVOLVED
- Full Name: [NAME] Phone: [PHONE] E-Mail: [E-MAIL]
Address: [ADDRESS]
Identification: ☐ Driver’s License No.: [DL NO.] ☐ Passport No.: [PASSPORT NO.]
☐ Other: [OTHER IDENTIFICATION NO.] - Full Name: [NAME] Phone: [PHONE] E-Mail: [E-MAIL]
Address: [ADDRESS]
Identification: ☐ Driver’s License No.: [DL NO.] ☐ Passport No.: [PASSPORT NO.]
☐ Other: [OTHER IDENTIFICATION NUMBER]
INJURIES
Was anyone injured? ☐ Yes ☐ No
If yes, describe the injuries: [DESCRIBE INJURIES]
WITNESSES
Were there witnesses to the incident? ☐ Yes ☐ No
If yes, enter the witnesses’ names and contact info:
- Full Name: [NAME] Phone: [PHONE] E-Mail: [E-MAIL]
- Full Name: [NAME] Phone: [PHONE] E-Mail: [E-MAIL]
MEDICAL SERVICES
Was medical treatment provided? ☐ Yes ☐ No ☐ Refused
If yes, where was medical treatment provided? ☐ On site ☐ Hospital ☐ Other: [OTHER]