Incident Reporting Form
Were you a witness or a victim?
Do you live on or off campus?:
Date of Incident:
Time of Incident:
Location of Incident:
Number of Perpetrators:
Describe the Incident:
Would you like to be contacted by the Office of Student Life?:
Personal Contact Info
Note: If you are under 18 years of age and do not want to make an official police report, do not include your name on this form.
(Optional) if you woul like to be contacted, please provide the information below.
If Student, Classroom Status:
Years attending UW-Platteville:
If other, please describe:
Describe the nature of your relationship with the perpetrator prior to the incident:
Please include additional information if there is more than one perpetrator: