CORRECTIONS ASSAULT INCIDENT REPORT

INSTITUTION: DATE OF INCIDENT:

LOCATION OF INCIDENT: TIME OF INCIDENT:

______________________________________________________________________

DESCRITION OF ASSAULT:

VICTIM NAME (S):

CONDITION OF VICTIM (S) AND MEDICAL ATTENTION REQUIRED:

WAS THIS INCIDENT REPORTED TO SUPERVISION?

REPORTING PERSON__________________________________

DATE REPORTED TO AFSCME__________________________

Please fax, mail, or E-mail this report to AFSCME council 5