Incident Report Form

Thank you for filling out an incident report. Members, chapters, volunteers and staff have a responsibility to promptly report all incidents where someone was possibly injured, damage occurred, or an incident that could result in campus, community or media attention or an insurance claim. Prompt reporting can often prevent minor incidents from developing into major problems. After filing an incident report and speaking with an Administrative Office staff member, chapters should also report appropriate Risk Management Policy violations to their host campus. In cases of serious bodily injury or death to any member, new member or guest, chapters are required to notify the host institution and the associated public safety department or the local police department.

Names and contact information are requested for the purposes of creating a record. We encourage you to be open and honest with the information you submit. Reports can be filed anonymously by members of the public. In that case, complete the required fields with as much information as you’d like to share. The level of detail Fraternity members and community members provide directly impacts the Fraternity’s ability to respond appropriately to an allegation or claim. To that end, the ideal “Narrative” will include details about individuals

Reports of hazing can also be reported to the Anti-Hazing Hotline at 888-668-4293 (888-NOT-HAZE). Callers may remain anonymous or they can provide personal information so their concerns can be responded to directly.

If you have questions or concerns about this form, whether a form is warranted, or would like guidance on how to best complete the form, please contact the Administrative Office at 800.800.BETA (2382).

Crisis Guidelines and Resources

Crisis Communications Protocol

If you have documents, photos or other media that is relevant to this report, please submit via email to incident@beta.org immediately after submitting this report form.

Fraternity or Community Member Information

Beta Chapter or Campus

Your Full Name*

Your Phone Number*

Your Email Address*

Your Chapter/Community Position

Primary Persons Involved Information

His/Her Full Name*

His/Her Phone Number*

His/Her Email Address*

His/Her Affiliation*

Primary Persons Involved Information (Secondary)

His/Her Full Name*

His/Her Phone Number*

His/Her Email Address*

His/Her Affiliation*

Incident Details/Narrative

Incident Type*

Incident Date*

Approximate Incident Time*

AM/PM*

Incident Details*

Incident Location*

Was anyone injured?*

If yes, what's the nature of the injury?

First Aid Administered?

Who administered first aid?

Notification of Officials

Type of Official

Beta Staff:

Who did you notify	Notification Date	Time

Beta Volunteer:

Beta Volunteer 2:

Greek Life Official:

University Official:

Campus Police:

City Police:

Fire Department:

House Corporation:

Other:

Additional Information

Was the Media Involved?*

What actions has the chapter taken thus far?*

Witness Contact Information

Witness Name

Witness Phone Number

Witness Email Address

----- Witness 2 Contact Information -----

Witness 2 Name

Witness 2 Phone Number

Witness 2 Email Address

----- Witness 3 Contact Information -----

Witness 3 Name

Witness 3 Phone Number

Witness 3 Email Address