INCIDENT REPORTING FORM

Instructions: Form is to be completed by the Complainant and signed by the Complainant and Borough Manager or Unit
Head. Copies and any relevant reports or documentation should be distributed as follows:
Investigations and Disciplinary Unit IAD (original copy)
Assistant Commissioner / Administration
Director of Contracts & Purchasing
Director of Budget and Fiscal Affairs
Requests for replacement of equipment must include a copy of this report.
A.
Name: Title:
Address:
Unit: Office Phone: Home Phone:
Date of Report:
B.
Date of Incident: Time of Incident:
Location of Incident (Address / Unit Area):
Type of Incident: Theft Property Damage Other (Explain)
Was Entry Forced? Yes No Attempt
Did Complainant Witness Incident?
Can Complainant Identify Perpetrator?
C.
If incident involved stolen / damaged vehicle*:
Plate #: Make: Model: Year: Color:
Location at Time of Damage:
Description of Damage:
Items taken along with Vehicle (e.g. Parking Permit):
*A completed “Driver’s Accident Report” and “Vehicular Incident Evaluation Report” is required in cases involving vehicular
accidents.
D.
If incident involved other property:
Property: Business Personal
Article Quantity
Description (Brand, Model, Serial #)
E.
Additional Complainants / Witnesses:

F.
Reconstruction Occurrence (Method of Entry / Escape; any other details):

G.
NOTIFICATION – By whom, if other than Complainant:
Police / Precinct #: Complaint #:
Individual Notified: Date / Time:
DCAS / City-Owned Building: Report Attached:
Individual Notified: Date / Time:
Building Manager:
Individual Notified: Date / Time:
H.
SIGNATURE: DATE:
(Complainant)
SIGNATURE: DATE:
(Borough Manager / Unit Head)

ADM-23 (Rev. 5/03)