Campus Incident Report Form
All students, employees, or visitors should promptly report criminal incidents, accidents, and other emergencies to the Safety and Security Department, by dialing extension "1777."

You can also report a criminal incident in person at the Information Desk, located in the Student Center building. Campus Security will also assist students who wish to contact the Vineland Police Department.

When a report of a criminal act, safety-related issue or violation of College policy is made to the Campus Security Department, a Security representative will respond to investigate the facts. The Security representative may make a report or may log the incident on his/her daily log, depending upon the nature of the incident. The Security representative will collect information, interview witnesses and participants, and may refer the reporting party to a law enforcement agency. The Security representative may also summon medical aid or law enforcement when necessary.

Confidential reports will be taken when an individual does not want his or her identity publicly revealed in the reporting of a crime or other serious incident.

When you report a potential emergency, or suspected criminal activity, be prepared to provide the following information: Type of incident, location of incident, description of persons involved (if criminal in nature), suspected injury or condition (if medical emergency), your name, location, and number you are calling from.

Please fill out the form below to report an incident to the Campus Security Department.
DO NOT USE THIS FORM FOR REPORTING OF EMERGENCY SITUATIONS, INCIDENTS THAT ARE IN PROGRESS, OR REQUIRE IMMEDIATE ATTENTION.

IF YOU NEED IMMEDIATE SERVICE OR HAVE AN EMERGENCY, PLEASE CONTACT CAMPUS SECURITY AT EXTENSION 1777.

Complete the form and submit
Today's Date:
MM
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DD
/
YYYY
Incident Date:
MM
/
DD
/
YYYY
Time of Incident:
Time
:
Incident location:
Your answer
Type of Incident:
If other, please describe:
Your answer
Your Connection to CCC:
If Employee, enter your job title:
Your answer
Department:
Your answer
Your involvement with Incident:
If other, please describe:
Your answer
Description of Incident
Please be as detailed as possible, including all relevant information:
Your answer
Others involved in incident, including witnesses:
Full Name:
Your answer
Phone Number:
Your answer
Involvement:
Your answer
Email:
Your answer
Others involved in incident, including witnesses:
Full Name:
Your answer
Phone Number:
Your answer
Involvement:
Your answer
Email:
Your answer
Others involved in incident, including witnesses:
Full Name:
Your answer
Phone Number:
Your answer
Involvement:
Your answer
Email:
Your answer
Local Police Notification:
If Yes, what department?
Your answer
Before you submit, read this.
I have read this statement and I certify that the facts contained herein are true and correct. Dishonest reports and/or false claims may result in potential disciplinary action against you by Cumberland County College.

If you wish to report this incident in person or by telephone, please contact the Information Desk/Campus Security, located in the lobby of the Student Center Building, Mondays through Fridays, 7 AM to 10 PM , Saturdays, 7 AM to 2 PM, or call (856) 691-8600 ext, 1777.

First Name:
Your answer
Last Name:
Your answer
Address:
Your answer
City:
Your answer
State:
Your answer
Zip:
Your answer
Home Phone:
Your answer
Cell Phone:
Your answer
Email:
Your answer
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