Incident Report Form
Please use this form to send Staff members BSC Central Office a statement about an incident you witnessed or experienced.

Your answers & any personal information will be kept confidential by the BSC to the extend possible for the purposes of investigation.

For questions about what happens after you submit this form - contact the BSC's Member Resources Coordinator (MRC), Portia Lewis mrc@bsc.coop and CC Co-Interim ED Dave Chelsea-Seifert interimed1@bsc.coop. 

The Cooperative Experience (CEM) Manager position (cem@bsc.coop) is currently VACANT.

For Immediate Emergency Member Support contact (510) 812-9384

[The Berkeley Student Cooperative is a student-run 501(c)(3) affordable housing provider that removes barriers to higher education for low-income and traditionally marginalized students and empowers them with community-building skills that they can take into the future.]
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Email *
Untitled Title
Your Name and Manager Title, if applicable *
BSC Unit You Live in
Your Email Address *
Your cell number & best times to call *
Name(s) of People Involved in the Incident *
Date of Incident *
MM
/
DD
/
YYYY
Time of Incident *
Time
:
Where did the Incident take place?
Description of Incident. Please tell us what happened, focusing only on the facts, not your opinion. *
It is recommended that you write this in a google doc or a word doc, then copy and paste the description into this form. If you need more information on writing a description of an incident: https://docs.google.com/presentation/d/1qlcQcAODPHtmWWdV7n03zBjYVZN6FFGk1ql6_9G0vmQ/edit?usp=sharing.
Was anyone physically injured? *
Was medical treatment provided? Explain. *
Is there anything else you would like to add?
What type of incident report are you submitting? *
Required
Would you like support from Central Office with this incident report? *
This helps the Cooperative Experience Department prioritize responding to incident reports if a lot of incident reports are submitted simultaneously. All incident reports submitted will be addressed in 48 hours.
A copy of your responses will be emailed to the address you provided.
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