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Incident Report
This form is to be used to report an incident or accident to Lambda Phi Xi, Multicultural Sorority, Inc.
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* Indicates required question
Email
*
Your email
Phone number
*
Your answer
Name "Line Name" Last Name
*
Your answer
* If you are not an inducted member of Lambda Phi Xi, you may leave the line name section blank.
Date of Incident
*
MM
/
DD
/
YYYY
Location and time of incident
*
Your answer
Please detail the incident or accident you are reporting to the best of your ability. (Describe what happened, who was involved, nature of the injury, part of body affected, etc.)
*
Your answer
Witness Name(s)
*
Your answer
I ________________, certify that all of the information above is to the best of my knowledge, correct and complete.
*
Your answer
Sign Your Name
By signing, I attest that the information stated above is correct to the best of my knowledge. I understand, depending on the severity of the situation, an investigation may take place to reach a resolution regarding the incident or accident I am reporting.
Sign Your Name
*
Your answer
Today's Date
*
MM
/
DD
/
YYYY
A copy of your responses will be emailed to the address you provided.
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