First Name
Last Name
Position/Title/Role
Phone
Email
Date of incident
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Time of incident
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Location of incident - be specific as possible
Person(s) of concern
Please provide any known contact information about the individual(s) involved in the incident. Provide as much detail as possible.
Name of Person of concern (first and last name)
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Perceived gender
Male
Female
PSC ID number of person involved
Date of birth of person involved
Phone number of person involved
Email address of person involved
Address of person involved
Add information for another person involved
Summary of incident
Complete the following based on what you observed or what has been reported to you. Provide as much detail as possible.
What is the purpose of this report? Click all that apply.
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I am concerned about a possible threat of physical violence.
I am concerned for a persons well-being.
I want to report a possible policy violation.
I want the College to be aware of this incident.
I am not sure.
Describe in detail, the concern, incident, and/or behaviors that you observed or were reported to you.
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Please provide the names of any witnesses or other persons who may have additional information regarding this concern.
Is there anything else you would like to add?
By submitting this report, you are acknowledging that the information provided may be viewed by the appropriate College officials. The information will also be maintained in accordance with applicable college record keeping practices. (This includes the Family Educational Rights and Privacy Act (FERPA), which means that if information contained in this report leads to a formal student conduct process, the student(s) whose behavior is in question has the right to review the relevant content.)
I agree.
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