City of Janesville Web Site

Janesville Police Department

P.O. Box 5005
100 N. Jackson St. Janesville, WI 53547-5005
Phone: 608-755-3100 Fax: 608-755-3004

Self-Initiated Incident Report Form

PURPOSE: This form is used to report incidents that occur within the City of Janesville to the Janesville Police Department. Report content will be considered for either future investigation or maintained as a Department record. Self-initiated Incident Reports that are deemed inappropriate, lack jurisdiction, or are otherwise not within the scope of police responsibility will be returned to the sender.

INSTRUCTIONS: Complete all applicable portions of this form. Use full name(s) if known. Describe property with all available identifiers including serial numbers, if known. Explain the circumstances with details, including date, time and location. Incomplete information will delay report processing. You may deliver this report to the Janesville Police Department by e-mail, FAX, or in person.

Getting Started

In order to be able to use this form to report an incident, the incident must have occurred in the City of Janesville and you must also be able to answer "No" to the following questions. If the incident did not occur in the City of Janesville you must contact the law enforcement agency with jurisdiction where the incident occurred.

Is this an emergency?	Yes No
Is anyone injured?	Yes No
Was a weapon used or threatened to be used?	Yes No
Was any level of force used or threatened?	Yes No
Do you know who committed this offense?	Yes No
Did this happen in the City of Janesville?	Yes No

General

Incident Type
Incident Location*		Apt. #
Occurred Start*:	Date:	Time(mm:ssAM/PM)*:
Occurred End*:	Date:	Time(mm:ssAM/PM)*:

Contact Information

Your Name*:
E-mail*:	Phone:
May we contact you regarding this report?	YesNo
The best time to contact you is?	Time:
Preferred method of contact?	E-mailPhonePerson

*Required. If you don’t have an email address, you may print the report to submit by mail, FAX or in person.

Persons

Last Name	First Name	Middle	D.O.B.	Event Association	Race	Sex	Phone	Address

									Add

* In order to add a person, please fill out the person information and click the "Add". More than one person can be added to the form.

Business

Business Name:

Address:

Vehicles

Type	Year	Make	Model	Style	Lic. #	Lic. State	Event Association	Color	Owner Name

										Add

* In order to add a vehicle, please fill out the vehicle information and click the "Add". More than one vehicle can be added to the form.

Property

Owner Name	Event Association	Value	Brand/ Make	Model	Color	Serial Number	Description

								Add

* In order to add a property, please fill out the property information and click the "Add". More than one property can be added to the form.

Please briefly describe this incident:

The preceding information is provided to the Janesville Police Department for whatever purposes the police department deems necessary. I certify the information contained herein is true and correct to the best of my ability.

OR