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MJC Student Conduct Report Form

Use this form to document violations of the YCCD/MJC Standards of Conduct. If you have any questions related to completing this form you may contact the Student Conduct office at (209) 575-6022.

This report should be filed after your communication with the student where you have described the consequences and that this report is being filed. Please remember that all information contained within this report may become part of Modesto Junior College's administrative record keeping and may be available to the students to which they pertain under FERPA. Be professional, accurate and factual. Recitations of observations and facts are more useful than characterizations or labels.

Please note that anonymous reports are not accepted and no action will be taken.

Reporter's Information

Your full name:

Your position/title:

Your phone number:

Your email address:

Email address must be of a valid format.

Nature of this report(Required):

This field is required.

Division or Office(Required):

This field is required.

Date of incident(Required):

This field is required.

Time of incident:

Location of incident(Required):

This field is required.

Specific location:

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Example: ENGL-101-1234, Founders Hall, Room 100

Involved Parties

Please list the individuals involved (EXCLUDING yourself), including as many of the listed fields as you can provide. In the "W Number" section ONLY report the seven digits (DO NOT USE THE W, JUST NUMBERS). For non-students, please list the driver's license in the "W Number section," if available.

Note: "Alleged" refers to the individual about whom you are reporting.

Name

Select Gender

Person Role

W Number (DO NOT ENTER THE W, JUST THE NUMBER)

DOB (YYYY-MM-DD)

Reason(s) for Report and Narrative

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

Reporter's Information

Involved Parties

Reason(s) for Report and Narrative

Supporting Documentation

Submission