•   Web Intake Incident Form

Welcome to the NYJC Incident Submittal Web Form

Welcome to the NYJC Incident Submittal Web Form


Do NOT use this web form to report an incident that is an emergency. If emergency services (medical assistance, law enforcement, fire department, etc.) are needed, contact 9-1-1 immediately. After contacting 9-1-1, contact NY Justice Center to report the incident.

Custodians can use this web form to report ALL reportable incidents, including those involving a death.

Directors (or other authorized person) of a Facility or Provider Agency are required to call the VPCR Death Reporting Hotline to report ALL deaths as required by the NY Justice Center.


 
   
 

Incident Address:

   
 


     
 

Provider Contact Address:

   
     


   
 
     
 
 

Reporter Contact Address:

     
     


  Suspect One

   
 

Suspect One Contact Address:

   





  Victim One

   

Victim One Contact Address:

   





   

Witness Contact Address:

   





*  




All the details on this report will be lost. Do you really want to cancel this operation?