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I am a:
Phone Number (include country/area code if applicable)
Program Name, if known:
Date, Time, and Location of Incident:
Name(s) of those involved in the incident :
If possible, please provide full name(s).
Student ID#(s) of those involved in the incident, if known:
List one ID# per line.
Others involved in the incident:
Type N/A if not applicable.
Please check the appropriate box(es) to indicate the nature of the incident:
Arrest of Student
Assault of Student
Other, please specify:
Please describe the incident. Be specific as possible, including all details.
Have any emergency contacts been contacted for any of the parties involved?
I don't know
What actions or steps have been taken so far? Have the country's local authorities or the U.S. Embassy staff been contacted? Provide specific details below.
What assistance, if any is needed from VSU?
Nothing at this time
Contact reporter at the earliest convenience
Need to access services at VSU
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