TBE Incident Report Form

THIS FORM IS FOR—

1. Reporting and recording incidents or situations that might compromise safety or security at TBE. Examples might be: door left unlocked, window left open, accident in the building or on the grounds, etc.

2. Reporting a building and grounds problem that needs repair.

PLEASE DO NOT USE THE FORM FOR—

1. Suggesting a security improvement. Please contact the Security Committee (security@tbeithaca.org) and use the form only if there’s an incident.

2. Reporting another type of incident, such as sexual harassment. Please contact the president (president@tbeithaca.com) or a member of the Board.

IN AN EMERGENCY, call 911 for immediate help.

IF URGENT and 911 is not needed, please notify one of the following:

Administrative Coordinator, Adeena Brown (607-273-5775)
House Committee, Jerry Dietz (607-327-1515)

* First Name

* Last Name

* Phone number

* Email

* Please describe the incident/situation and location

* Date and time it was observed, and when it may have occurred (if it differs)

* Did anyone else observe the incident?

* Was any outside intervention required? (such as ambulance, police or fire department, repair person)

* Is there any other information to share?

Note: This form will be copied to the Temple Beth-El President, Security Committee and any other TBE persons who may need to address the problem.

Sun, August 17 2025 23 Av 5785

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