Form: SCCC0003ELC Rev. 3/2013
SCHENECTADY COUNTY COMMUNITY COLLEGE
STATEMENT FORM
Report Date:
Report Time:
Date Occurred:
Time Occurred:
Location of Incident:
Room:
Nature of Incident:
Notifications: Sch’dy Fire Dept. Police Other: Medical Treatment: Yes No Refused
Person Filing Statement Status
Last
Name:
First: MI:
SCCC
ID#:
S E V
Person Involved(s)
Last
Name:
First: MI:
SCCC
ID#:
S E V
Last
Name:
First: MI:
SCCC
ID#:
S E V
Witness
Last
Name:
First: MI:
Ph #:
S E V
Last
Name:
First: MI:
Ph #:
S E V
Describe what happened, how it happened, factors leading up to the event, substances or objects involved. Was the individual injured? If so,
describe the injury (laceration, sprain, etc.), the part of the body injured and any other information known about the resulting injury (s). Be as
specific as possible. Attach a separate sheet if necessary.
Narrative:
Signature: Date:
Guards Printed Name: Signature: Date:
DISTRIBUTION:
Vice President Administration Assistant V.P. Administration Vice President Student Affairs Security
Maintenance OTHER:
S = Student, E = Employee, V = Visitor
