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, State Government agencies, Private organizations 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. Name of Person Reporting Incident Title Telephone Number Email Agency Locality Date of Incident Time of Incident Nature of Incident 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- medical emergencies Spills or exposure to hazardous substances The presence of unauthorized persons or trespassers Other 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? - Select - Yes No If an incident command center is not opened, is one expected to open? - Select - Yes No Name and telephone number for the on-site liaison Is a Family Assistance Center expected to open within the next 24 hours? - Select - Yes No Has the local victim/witness program been notified? - Select - Yes No Additional Comments CAPTCHA Math question 2 + 4 = Solve this simple math problem and enter the result. E.g. for 1+3, enter 4. This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. Protected by Spam Master
