1. Delgado Community College

Violence Incident Statement

NOTE: The contents of this document is to be kept CONFIDENTIAL with its contents released only to individuals with a legitimate need to know or unless it is determined to be public record in accordance with the state’s public records law, or through an appeal to a court or other adjudicative body.

Date of Incident

Place of Incident  

Time Incident Began

Time Incident Ended  

Person  
Making  
Statement

Telephone  
Number  

Title

Work  
Location  

Detail description of incident. Answer the questions WHO, WHAT, WHEN, WHERE, HOW and WHY. (If necessary, continue on plain paper; attach sheets.) Completed statement   should be forwarded to appropriate personnel.