Statement

Incident Statement

Public Safety Incident Statement Form

This form is not intended to report new incidents. Please contact The Department of Public Safety directly at 802-443-5911 to file an initial report and to receive a case number. The below fields are to be filled out after an existing incident has been reported.

Students, Faculty, & Staff should log-in to the website before submitting to help ensure accurate information
Please fill out this form as completely as possible and be sure to include the following:
- Location, Individuals’ names and/or descriptions, time, reason incident occurred
- For theft or damage: Item, Description, Serial Number, & Estimated Value

Personal Information

Full Name: *

Please Enter your Full Name

ID Number:

Please enter your 8 Digit ID number

Cell Phone Number: *

Enter your Full 10-digit Cell phone number (If no cell number, enter the best phone number for contact)

E-mail Address: *

Please enter your e-mail address. You will receive a copy of this statement form for your own records by e-mail automatically.

Non-Students - Click Here to Enter Address Information

Non-Students - Please fill out the following information.

Home Address:

Please include your apt. # street address, town, state, & zip code

Home Phone:

Please enter your Home Phone number

Date of Birth:

Please Enter your Date of Birth

Case & Statement Information

Please Fill out the below fields as completely as possible.

Case Number: *

This case number is provided to you by Public Safety. Please contact us at (802) 443-5133 if you have not yet received a case number.

Type of Incident: *

Please enter the type of Incident that occurred (Theft, Assault, etc...)

Date of Incident: *

Please enter the date the incident occurred

Time of Incident:

Enter the Time of Day the incident occurred. If unsure, of exact time, please note this in the body of the statement.

Location of Incident: *

Please Enter the locaton the incident occurred. (i.e. Ross Dining Lounge, The Grille, Juice Bar, Etc...)

Statement: *

Please enter as much information as you can remember. Include (if possible) the Who, What, When, Where, Why, and any other information you remember.

Email Address: