Incident Reporting Form

If you need to report an emergency, call Campus Safety at (306)626-3771, or dial 911.

The Office of the Dean of Students within the Division of Student Affairs at Florida Memorial University is charged with upholding the Student Code of Conduct, which identifies behavioral expectations for all students on and off campus. If you have knowledge of an FMU student violating the Student Code of Conduct, you are encouraged to notify our office of the incident.

Reportable behaviors may include Student Code of Conduct violations, a student who you feel may be struggling physically or psychologically, or any other behaviors of concern that you would like to see addressed or would like to discuss. When completing this form, please include your name, title, and contact information. Please note that anonymously submitted forms may limit our effectiveness in dealing with concerning behavior.

Furthermore, please realize that the individuals involved may be afforded certain privacy rights under the Family Educational Rights and Privacy Act (FERPA) which established requirements regarding the privacy of student records. Please note that students have the right to inspect any information submitted regarding this matter.

Incident Reporting Form
Fields marked by * are required.
Section A
FMU Affiliated: *
Full Name:
Phone Number:
Email Address:
Physical Address:
Nature of Report: *
Urgency: *
Section B
Type of Incident
Category of Prejudice: *
Date of Incident: *
Time of Incident:
Location of Incident: *
Specific Location:
Section C
Please list the individuals involved (excluding yourself), including as many of the listed fields as you can provide. For non-students, please list a Driver’s License number in the block labeled “ID Number”, if available. To add another person please click ‘ADD’)

  • Male
  • Female
Reporting Party:
ID Number:
Date of Birth:
Phone Number of Individuals:
Email Address of Individuals:
Hall / Residence:
Section D
Description / Narrative:
Please describe, in as much detail as possible, the specific behaviors/alleged violations observed. Avoid using pronouns (he, she, etc.) to identify people. Indicate specific words, phrases, and behaviors, including dates and times.
Section E
Additional Information
External Units Involved:
Select What Applies:

  • MGPD Involved
  • Campus Safety Involved
  • Arrest
  • EMS Transport
  • EMS Called – Refused
  • EMS Called – No Transport Needed
  • Voluntary Commitment (Mental Health)
  • Involuntary Commitment (Mental Health)
  • N/A