BC 1206 Bc1206

User Manual: BC-1206

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FORM BC-1206
(11-8-99)
U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration
SECURITY
INCIDENT REPORT
Date Time
1. Incident
p.m.
p.m.
3. Complete address where incident happened
(Street, city, State, ZIP Code) OR
(Room/Building)
4. Person
completing
report
b. Signature
c. Telephone
number
d. Division or Region e. Building f. Room No.
Area code Number
5. Type of incident
ADP
Assault
Theft – Government
6. Was medical attention
received?
Yes
No
Other – Explain
7. Details of incident – If additional pages are needed, mark (X) this box and attach.
8. Who was notified of incident – Mark (X) all boxes that apply
Police
F.B.I.
Sheriff
FPO
Supervisor
Census Security Office
Division/Regional Security
Representative
Administrative Office
Other – Specify
9. Police report number (If applicable)
Attached Will follow
10. Persons involved in incident – Attach additional pages, if necessary.
Codes for column (a): W– Witness V– Victim or Complaintant O– Investigated by M– Medical personnel
Code
(a)
Name
(b)
Telephone
(c) Street, city, State, ZIP Code
(d)
CENSUS SECURITY OFFICE USE ONLY
11. Disposition of incident – If additional pages are needed, mark (X) this box and attach.
12. Signature of person closing this incident 13. Date incident was closed 14. Incident number
2. Report
Date Time
a. Name
Theft – Personal
Area code Number
Date received – Stamp
CENSUS SECURITY OFFICE USE ONLY
U.S. CENSUS BUREAU
a.m.
a.m.

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