Custodial Notification Report

2. ** Take photo with phone prior to filling out form.

4. First Name*

5. Last Name*

7. Phone Number*

   Please provide the best phone number to call you on.

8. Email*

10. Site/Location of Incident:*
    -- Select One --30 N. Market Street Frederick, MD 21701Myersville Library, 8 Harp Pl, Myersville, MD 21773Adult Detention Center, 7300 Marcie's Choice Lane Frederick, MD 21704Animal Control, 1832 Rosemont Avenue Frederick, MD 21702Animal Health Lab, 1840 Rosemont Avenue Frederick, MD 21702Ballenger Creek Park Community BuildingBourne Bldg.-DPW/Parks, 355 Montevue Lane Frederick, MD 21702Brunswick Branch Library, 915 N. Maple Street Brunswick, MD 21716C. Burr Artz Library, 110 E. Patrick Street Frederick, MD 21701Catoctin Creek Nature Park, 2929 Sumantown Road Middletown, MD 21769Courthouse Complex, 100 W. Patrick Street Frederick, MD 21701DFRS Logistics - Scholl's Lane, Scholl's Lane Frederick, MD 21701Elections 340A Montevue Lane Frederick, MD 21702Emmitsburg Community Center, 300 S. Seton Avenue Emmitsburg, MD 21727Extension Service, 330 Montevue Lane Frederick, MD 21702Family Partnership, 8420 Gas House Pike Frederick, MD 21701Fountain Rock Park & Nature Center, 8511 Nature Center Place Walkersville, MD 21793Workforce Services, 200 Monroe Ave, Frederick MD 21701Frederick Senior Center, 1440 Taney Avenue Frederick, MD 21702Citizens Services, 401 Sagner Avenue Frederick, MD 21701Health Department Complex, 350 Montevue Lane Frederick, MD 21702Highway/Fleet Services Building, 331 Montevue Lane Frederick, MD 21702HSB- Jefferson Satellite, 3401 Burgee Drive Jefferson, MD 21755HSB- Johnsville Satellite, Coppermine Road HSB- Myersville Satellite, 10913 Old National Pike Myersville, MD 21773HSB- Thurmont Satellite, Blue Mountain Road Thurmont, MD 21788HSB- Urbana Satellite, 3471 Campus Drive Frederick, MD 21704LEC - Law Enforcement Center, 110 Airport Drive East Frederick, MD 21701Othello Regional Park, 1901 A Jefferson Pike, Knoxville MD, 21758Parks Maintenance-Shops/Bays, 430 Pine Avenue Frederick, MD 21701Public Safety Training Center (Annex Bldg), 5390 Public Safety Place Frederick, MD 21704Public Safety Training Center (Main Bldg), 5370 Public Safety Place Frederick, MD 21704John Hanson House, Near Courthouse on Patrick Street Frederick, MD Thurmont Regional Library, 76 East Moser Road Thurmont, MD 21788Transit, 1040 Rocky Springs Road Frederick, MD 21702Urbana Regional Library, 9020 Amelung Street Frederick, MD 21704Elections- Warehouse #1, 343 Montevue Lane Frederick, MD 21702Winchester Hall, 12 East Church Street Frederick, MD 21701Pinecliff Park - Browning Building118 N. Market StreetGreen Valley Fire Station #25, 3939 Green Valley Road Monrovia 21770340 B Montevue Lane- ALS, Frederick MD 21702Warehouse #2 341 Montevue Lane- CountyRose Hill Manor, 1611 North Market Street, Frederick, Maryland 21701Walkersville Branch Library, 2 South Glade Road, Walkersville, Maryland 21793Middletown Branch LibraryPt of Rocks, 1635 Ballenger Creek Pike, Pt of Rocks, MD 21777Utica District Park, 10200 B Old Frederick Rd, Frederick, MD 21701HIllcrest Clinic, 1100 W. Patrick St Unit H Frederick, MD 21701

12. Date of incident*
    Date of incident

    Date of incident

14. Description of Incident:*

16. Please provide picture(s) with this report
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    ** If attaching image from your phone, select the image from photo library.

18. Picture 1

19. Picture 2

20. Picture 3

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