Report a Campus or Local Emergency

This form may be used by public schools, state institutions of higher education, the Board of Health, regional emergency medical services councils, the Virginia Department of Emergency Management and local emergency management officials to contact the Department of Criminal Justice Services in the event of an emergency, as defined in the emergency response plan, when there are victims as defined in §19.2-11.01. Contacting the Department of Criminal Justice Services when these events occur is required as a result of the passage of HB2612 and SB1150 (affects the Code of Virginia §22.1-279.8, 23-9.2:9, 32.1-111.3, 32.1-111.11, 44-146.18, and 44-146.19)

Name of Person Reporting Incident:
Title:
Telephone Number:
Email Address:
Agency:
Locality:
Date of Incident: (ex. 01/01/2009)
Time of Incident: (ex. 07:30 AM)
Nature of Incident
Select Bus or other Accident involving severe injuries Student or Staff Member Death Explosion Bomb Threat Gun, Knife, or other Weapon threat Loss, Disappearance or Kidnapping of Student Hostage Situation Violence on School Property or at School Activity Incident Involving Act of Terrorism Other Incident Posing Serious Threat or Harm to Students, Personnel or Facilities Loss or Disruption of power, water, communications or shelter Medical emergencies, including cardiac arrest and other life-threatening medical emergencies Spills or exposure to hazardous substances The presence of unauthorized persons or trespassers Other Fire Flood Tornado Other Severe Weather
Please briefly describe the incident that you are reporting:
Potential number of crime victims as defined by §19.2-11.01:
Has an Incident Command Center opened?:	YesNo
If an incident command center is not opened, is one expected to open?:	YesNo
Name and telephone number for the on-site liaison: (ex. Harvey Smith   (804) 333-2222)
Is a Family Assistance Center expected to open within the next 24 hours?:	YesNo
Name and telephone number for the on-site liaison: (ex. Harvey Smith   (804) 333-2222)
Has the local victim/witness program been notified?:	YesNo
Additional Comments:
*Enter text from box above: