Use this form to provide information about the incident you are requesting a report for. Please provide as much information about the incident as possible so we can best serve you. You can expect to hear back about your Incident Report Request within two full business days after you make your request (excluding holidays and weekends). Production of your report may take longer depending on the type of incident, any non-disclosable or confidential information contained therein, or the ongoing investigation of an incident.

Incident Information

Date of incident:*

Time of incident:

Location of incident:*

Type of incident:*

Requester's relationship to this incident:*

Contact Information

First Name*

Last Name*

Business Name (if applicable):

Address*

City*

State*

Zip*

Phone Number*

Email*

Date of request:*

Time of request:*

Signature of person making the request:*

Do you agree?

By clicking 'I Agree' you agree and acknowledge that 1) your Incident Report Request will not be "Signed" in the sense of a traditional paper document and 2) By signing in this alternate manner, you agree that your electronic signature is valid and binding upon you to the same force and effect as a handwritten signature.*

I Agree