Safety and Security Forms
The forms included below should be completed and then turned in to the Safety and Security Department. In
those cases where the faculty, staff, or student is on one of GBC's campuses they should
contact the Campus Director or in Elko Security so information may be obtained directly and,
if required, photos taken. If an incident occurs while traveling the state, please let your
Supervisor know at your earliest convenience from a safe location.
The following forms are available from this site:
- Claim Against the State of Nevada (PDF*),
Use to file a tort claim against the State of Nevada for an incident or accident in which a NSHE employee or agency has caused injury or damages to another party due to a wrongful or negligent act.
- Driver Acknowledgement Form (PDF*),
The driver acknowledgment form must be completed prior to GBC faculty and staff checking out a motor vehicle or gasoline cards for use with a rental vehicle for GBC/NSHE business. Forms must be re-submitted after your driver's license renewal.
- Motor Vehicle Accident (PDF*),
Use when a motor vehicle accident occurs involving a third-party, whether or not there is damage or injury.
- Security Incident Report Witness Statement (MS Word), or Printable Adobe PDF (*pdf)
for use by any witness or person filing an incident report with Security or a Campus Director.
This statement should be turned in to the Safety & Security
- Property Loss Report (PDF*), use
for reporting thefts or damageto NSHE Property that exceeds $2,000 (excluding Motor Vehicles)
and for reporting boiler and machinery losses that exceed $2,000.
- Windshield/Glass Loss Report (PDF*),
for use by an NSHE employee driving an agency vehicle when a window is broken. This report should
be turned into the Safety & Security Director along with a witness statement explaining
the circumstances of the damage.
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