Faculty Removal of Disruptive Student from Class

Background Information

Faculty Name:

Course Name & CRN:

Faculty phone number:

Faculty email address:

Email address must be of a valid format.

Nature of this report(Required):

This field is required.

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Note: Student is allowed to return to class after the specified length of removal.

Urgency of this report(Required):

This field is required.

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Critical - Threatening situation that will affect the life/health of faculty, staff, or students

Date of incident (YYYY-MM-DD)(Required):

This field is required.

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Please enter in YYYY-MM-DD format

Time of incident:

Location of incident(Required):

This field is required.

Specific Location or Classroom:

Involved Parties/Witnesses

Please list the individuals involved (excluding yourself), including as many of the listed fields as you can provide. For non-students, please list an SSN or Drivers License number in the block labeled CSID (Student ID #) if available.

Name

Select Role

CSID Number

Student Phone number

Student Email address

Questions

Please answer the questions below. Please note that all responses will be a part of the student's case file and is subject to an audit.

Faculty cell phone number (optional - used only if unable to reach office/main number) This field is required.

Did the student leave voluntarily?(Required)

Yes No

This field is required.

College Police Contacted(Required)

Yes No

This field is required.

Description of Incident (please be as descriptive as possible)(Required) This field is required.

Action taken by Faculty:(Required) This field is required.

Action taken by College Police (if applicable): This field is required.

Supporting Documentation

Photos, video, email, and other supporting documents may be attached below. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

Email me a copy of this report

Background Information

Involved Parties/Witnesses

Questions

Supporting Documentation

Submission