Library Patron Incident Report Form
Use this form to report and document any incidents involving patrons or events occurring on library premises.
Date and Time of Incident
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Location of Incident (e.g., Reading Room, Entrance, Children's Section)
*
Type of Incident
*
Please Select
Disruptive Behavior
Theft
Property Damage
Injury/Medical Emergency
Harassment
Lost Item
Other
Describe the Incident in Detail
*
Names and Roles of Individuals Involved (e.g., Patron, Staff, Witnesses)
*
Were Emergency Services Contacted?
*
Yes
No
Actions Taken by Staff
*
Is Follow-Up Required?
*
Yes
No
Contact Information of Person Completing This Report (Full Name)
*
First Name
Last Name
Contact Email Address
*
example@example.com
Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Upload Supporting Files or Evidence (if any)
Upload a File
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of
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