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PSCOA Incident Report

Pennsylvania State Corrections Officers Association

    Your First & Last Name:

    Your Email Address:

    Subject

    Your Classification:

    (CO1, FSI, MR1, etc.)

    Institution:

    Date Of Incident:

    Shift (When it Occurred):

    Time of Incident:

    Management Staff Notified:

    Rank and Name

    DC-121 Filed:

    Description of Incident:

    Description of Injuries:

    Staff Witnesses: