SECURITY 6/24/2019
Coconino Community College
Online Initial Statement of Incident or Crime
This online form may be used to report a crime, allegation of a crime or any suspicious activity.
All information submitted to Security is confidential, any reported crimes or allegations of crimes may be referred to
the appropriate law enforcement agency for investigation and appropriate action.
Employee or Student Code of Conduct issues may be reported to the Dean of Student Affairs and or the Director of
Human Resources.
All information must be completed to facilitate Security in processing your reported incident or concern.
This form is also available for download and printing.
Date of Incident: Date Incident Reported:
Time of Incident: Time Incident Reported:
Location of Incident:
Reporting Party
First Name: Middle Name: Last Name:
Date of Birth: ID Number @
Residential Address
City: State: Zip:
Cell Number: Work Number:
Email Address:
Employer / Department:
Job Title:
Employment Address:
City: State: Zip:
Student or Involved Individual
First Name: Middle Name: Last Name:
Date of Birth: ID Number @
Residential Address
City: State: Zip:
Cell Number: Work Number:
Employer / Department:
Job Title:
Employment Address:
City: State: Zip:
SECURITY 6/
24/2019
Student or Involved Individual
First Name: Middle Name: Last Name:
Date of Birth: ID Number @
Residential Address
City: State: Zip:
Cell Number: Work Number:
Employer / Department:
Job Title:
Employment Address:
City: State: Zip:
Student or Involved Individual
First Name: Middle Name: Last Name:
Date of Birth: ID Number @
Residential Address
City: State: Zip:
Cell Number: Work Number:
Employer / Department:
Job Title:
Employment Address:
City: State: Zip:
Brief synopsis of the incident to include any witnesses and the specific location of the incident
Describe Incident:
Signature:
SUBMIT COMPLETED FORM
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