UTA Libraries Incident Report Form

This incident reporting form should be used to report behavioral misconduct and major facilities incidents in the West Library, Central Library, Library Collection Depository, Science and Engineering Library or Nedderman Hall.

For immediate misconduct or fire in progress assistance, please contact UTA Police 817.272.3003 or dial 9-1-1.

For immediate assistance with major facilities issues such as flooding, equipment fires not needing the Fire Dept, etc. contact the Office of Facilities Management at 2-2000.

In both cases contact Kevin Schuck, Director of Organizational Operations at 2-0102 or 817-723-6983.

Name Of Library Staff Submitting Report Name Of Library Staff Submitting Report First Last
Library Staff Email
Department
Reporting Party Information
Name of Individual (if applicable) Name of Individual (if applicable) First Last
Position/ Title
Name Name First Last
Select Gender (If Library Staff is reporting, this question can be skipped.
Involved Party (
Name of Individual Name of Individual First Last
Individual Email (if applicable)
Individual Phone (if applicable) Individual Phone (if applicable) - ### - ### ####
UTA staff, faculty, student or non related person

UTA staff, faculty, student or non related person UTA Student UTA Staff/ Faculty Member Non UTA related person
To the best of your knowledge, has this person been involved in any previous incidents?
If UTA student, staff or faculty member, please provide 1000#
Additional Involved Party

Please use this section to add additional participants
Name of Individual (if applicable) Name of Individual (if applicable) First Last
Select Gender
Individual Email (if applicable)
Individual Phone (if applicable) Individual Phone (if applicable) - ### - ### ####
UTA staff, faculty, student or non related person

UTA staff, faculty, student or non related person UTA Student UTA Staff/ Faculty Member Non UTA related person
To the best of your knowledge, has this person been involved in any previous incidents?
If UTA student, staff or faculty member, please provide 1000#
Additional Involved Party

Please use this section to add additional participants
Name of Individual (if applicable) Name of Individual (if applicable) First Last
Select Gender
Individual Email (if applicable)
Individual Phone (if applicable) Individual Phone (if applicable) - ### - ### ####
UTA staff, faculty, student or non related person

UTA staff, faculty, student or non related person UTA Student UTA Staff/ Faculty Member Non UTA related person
To the best of your knowledge, has this person been involved in any previous incidents?
If UTA student, staff or faculty member, please provide 1000#
If there are additional participants in the event, please add their name, 1000# and other pertinent contact information here.
Nature of Incident
Incident Time: Incident Time: : HH MM AM/PM
Date Date / MM / DD YYYY
Incident location building
Incident location floor
Please select the incident location
If incident location is not listed above, please list it here with room, room number and floor
Incident Type: Select all that apply.

Incident Type: Select all that apply. Medical- Transport Medical- Physical Injury Threats of Self Harm Threats of Harm to Others Patron Issue Building Access or Alarm Evacuation/ Fire Alarm / Fire Lockdown Shelter Theft Disruptive Behavior Unusual Behavior Drugs Arrest Flooding Electrical Plumbing HVAC Other Other
If medical transport, please indicate the hospital or emergency room individual was sent to.
Emergency level

High (H) — Widespread
• A large number of people are affected and/or are in some way exposed to acute disadvantages.
• Damaging the reputation or property of the organization on a large scale is likely.
________________________________________
Medium (M) — Localized
• A moderate number of people are affected and/or experience limitations in comfort.
• Damaging the organization's property or reputation on a moderate scale is likely.
________________________________________
Low (L) — Individualized
• A minimal number of people are affected and/or experience limitations in comfort, but only to a limited extent.
• Damaging the reputation or property of the organization is expected to only be a minimal extent.
Please describe the incident using as much detail as possible, include any specific concerns. Try to focus on the Who, What, When, and How of the incident. If possible try to use specific quotes such as offensive or threatening language. If UTA PD responded to the incident, please include police report number.
Please upload any supporting documents

Attach Files
Action/ Resolution

UTA Police Emergency: 2-3003
UTA Police Non Emergency: 2-3381
Office of Facilities Management After Hours: 2-2000
Libraries Director of Organizational Operations: 2-0102
Notification: (check all that apply)

Notification: (check all that apply) UTA Police Supervisor / Director Library Organizational Operations EH&S
Description of action/ resolution

UTA Libraries Incident Report Form

Reporting Party Information

Involved Party (

Additional Involved Party

Additional Involved Party

Nature of Incident

Action/ Resolution