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2. Date/Time:*
   Date/Time:

   Date/Time:
4. Staff Member Completing Form:*
6. Name, address and phone number of the person(s) involved in the incident:
8. Describe the Incident:*
10. Incident Location:*
12. Name and contact information of anyone that witnessed the incident:
14. Library Staff Involvement:
16. Suggested Follow-up:
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18. 1. Receive an email copy of this form.
19. Email address

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