Incident Report Form

Use this form to lodge an incident report, misconduct, safety risks, injury or inappropriate behaviour.

If someone is in immediate physical danger, contact 000.

If on a Swinburne campus, also contact Swinburne Security at (03)9214 3333.

You can also report incidents via Safer Community safercommunity@swinburne.edu.au

First Name

Last name

Student ID (if applicable)

Email

Phone

Are you reporting this incident on behalf of someone else

Yes

No

Which area does this incident relate to?

Clubs and Sports Event

SSA Event

Date of the incident

Location of the incident

Description of the incident

Was anyone injured?

Yes

No

Was any student involved intoxicated with Alcohol/Drugs?

Yes

No

What type of incident was it?

You may choose more than one category if applicable

Supporting evidence

Evidence is not required but can help us assess your report more accurately.

Do you want SSA to contact you about this report?

Yes

No

By submitting this form, I understand and acknowledge that the SSA may contact me regarding the matter I have raised. I also consent to my personal details and the information provided in this form being shared with relevant third parties, where necessary, to investigate or respond to the incident appropriately and in accordance with applicable laws and organisational policies.

I understand that intentionally submitting false and or misleading information may result in disciplinary action taken including under Swinburne's Student Charter.