Michigan Public Employees SEIU Local 526m

Please complete this form with as much information as possible. We will get back with you via phone or e-mail if clarification is needed.

e-mail*

First Name*

Middle Name

Last Name*

Facility*

Today's Date*

Date of Incident

Location in Facility

# of staff involved

# of inmates involved

# of staff injured

If a weapon, what type?

Description of Incident:

Management's response and any problems with it:

Suggestions for how this could have been prevented:

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421 W. Kalamazoo St., Lansing, MI 48933 | 517-485-3310 toll-free: 800-451-4878
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