Filled Out Incident Report

Bemidji State University
Department of Residential Life

INCIDENT REPORT FORM

Reported by: Joe Schmoe Position: RA 1333 Orchard Hall
Date reported: 2-31-08 Phone: (218) 333- 8896
Address: 1333 Orchard Hall 1062 West Addison
Date and Time of Incident: 2-30-08 11:58 p.m.
Place where Incident occurred: 1336 Orchard Hall

NATURE OF INCIDENT (Check all that apply)
__ Violation of Code of Conduct ___ Medical _ Suicide Gesture
Specify Code(s): _ Physical Injury _ Hospitalization
_ Psychological Problems _ Death _ Maintenance
x_ Other (Specify) Individuals Jane Doe and John Doe were throwing pumpkins out 13th floor window

NAME(S) OF INDIVIDUALS INVOLVED:

Name Address Telephone Signature
Jane Doe 1338 Orchard Hall 9999 Jane Doe
John Doe 1336 Orchard Hall 9998 John Doe

DESCRIBE THE INCIDENT IN BEHAVIORAL TERMS: There was a complaint by a passing resident Billy the Kid that pumpkins were “raining down” on him. The R.A. on 13th floor Joe investigated and found John and Jane throwing pumpkins out the window of 1336 shouting “I’m gonna get a bird!” The R.A. confronted the individuals who immediately ceased throwing pumpkins and replaced the screen on the window, without further incident.

Name(s) of Witnesses: Address:

Billy the Kid 1405 Orchard Hall

Person filing report Title Date
Joe Schmoe R.A. 13th floor Orchard Hall 2-31-08

My Signature acknowledges that I am aware of this report. It does not indicate either agreement or disagreement with the content of the report.
Joe Schmoe
6/06 C07

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