Student Conduct Reporting Form

Background Information

Your full name:

Your position/title:

Your phone number:

Your email address:

Email address must be of a valid format.

Conduct Disciplinary Report(Required):

This field is required.

Urgency of this report(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:

Involved Parties

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

Name or Organization

Select Gender

Select Role

ID Number

DOB (YYYY-MM-DD)

Phone number

Email address

Hall/Address

Incident Details

What is the approximate duration of the behavior(s) you are reporting?(Required)

Single Incident Ongoing

This field is required.

If the behavior is ongoing, when was it first observed? This field is required.

Description/Narrative - (WHO, WHAT, WHEN, WHERE, WHY, and/or HOW ) Please describe in as much detail as possible the specific incident that occurred. Avoid using pronouns, i.e., he, she, etc. to identify people. Use the person's real name when known in your description otherwise give the name you know the person by. Indicate specific words, phrases, interactions, and behavior. Give dates and times. If a subject used profanity, made threats, or spoke of harming him/herself, indicate specific words/phrases used. If a student was loud or disruptive, indicate behaviors associated with the disruption, and describe any injury or damage to a person(s) or property. If this is a student welfare concern, please describe the change in student's behavior that has prompted this report. Include name(s) of campus personnel you contacted and actions taken, if any.(Required) This field is required.

Did Chattanooga State Campus Police and Safety respond?(Required)

Yes No

This field is required.

Was anyone transported to the hospital; jail; or other facility?(Required)

Yes No

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

Incident Details

Supporting Documentation

Submission