Incident Reporting Form

Background Information

Your full name:

Your position/title:

Your phone number:

Your email address:

Email address must be of a valid format.

Your physical address:

Nature of this 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 an SSN or Drivers License number in the block labeled ID Number if available. The ECSU ID Number MUST include all nine digits (without dashes).

Name or Organization

Select Gender

Select Role

ID Number

DOB (YYYY-MM-DD)

Phone number

Email address

Hall/Address

Questions

Below are categories that correspond to the Student Code of Conduct. Please indicate the relevant sections that pertain to this incident report.

You must make at least one selection.

ACADEMIC

Buying, selling, stealing or soliciting examination content

Collusion on assignments submitted for credit

Disruption or obstruction of teaching / learning environment

Distance Education (Online Courses)

Forgery

Plagiarism

Substitution for another person during an exam or allowing

You must make at least one selection.

COMPLAINT AGAINST FACULTY

False Accusation(s)

Intimidation

Unfair Grading

You must make at least one selection.

REGISTRAR

Class does not appear on schedule

Course grade does not apppear

Dropped course appears on course schedule

Transcripts have not been received

You must make at least one selection.

TITLE IX

Dating Violence

Domestic Violence

Hate Crime

Rape

Sex Discrimination

Sexual Assault

Sexual Harassment

Stalking

You must make at least one selection.

Please provide a detailed description of the incident/concern using specific concise, objective language. This field is required.

Select any of the following that apply:

Arrest EMS transport EMS called - transport refused EMS called - no transport needed

You must make at least one selection.

Did police respond?(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

Questions

Supporting Documentation

Submission