Middlebury

 

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

Please Enter your Full Name

Please enter your 8 Digit ID number

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

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

Case & Statement Information

Please Fill out the below fields as completely as possible.

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.

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

Please enter the date the incident occurred

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

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

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