EMERGENCY REPORTING FORM
Information of Person Reporting Incident:
Name: Title:
Department: Building:
Office Phone: Cell Phone:
Email:
Emergency Information:
Space Occupant:
Facility Zone: Bldg./Loc.: Room: Type of Space: Classroom Research Office Lab Infrastructure
Residence Hall Room Other:
Are there any life safety dangers or risks as a result of this emergency? If so, have emergency services (Fire, UHPD,
EHS, etc…) been notified? Yes No
Is there any one trapped or stranded: Yes No Are the exits blocked? Yes No
How many occupants are there in the impacted space?
Provide a brief overview of the nature of the emergency. (Fire, Excessive Water, etc.?)
Describe visible damages to property. (What things are affected? How many rooms are under water? )
Describe any other relevant information regarding this incident or subsequent impacts you want to report.
FM Onsite Contact: ________________________________ Call Center Rep: ___________________________________ Date & Time:_ ____________________________________ Local Response Dispatched: _________________________ Response Time: ___________________________________ Cotton Assistance Required? Yes No If yes, who dispatched? ____________________________ when? _____________________________________ Confirm Cotton arrival: ____________________________ Has service level order been processed? Yes No