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Department of Public Safety

San Juan College

Department of Public Safety

Statement Form

Date Occurred * Time * Location *
Name of Person Making Statement * Age * Sex *
Email address of Person Making Statement *
Race * I.D. Number * I.D. Type *
Phone Number * Message Phone Number
Address * Apt. No.
City * State * Zip *
I attest that the statement I have given is true and accurate and I have given this statement of my own free will and accord and have not done so as a result of threat or promise. If this is correct, please input your first and last name in the signature box below.
Signature * Date
Employee ID or type in 'Visitor' *
Officer Name * Badge No. *
* Denotes a required field.
If badge number is unknown, please input 000.
If Officer Name is unknown, please input DNK

If you have suffered a work-related injury or illness,
contact the Department of Public Safety
at 566-3333 immediately.