Behavioral Reporting Form

Background Information

Your full name:

Your position/title:

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Please indicate if you are the following: HACC Employee, HACC Student, Not HACC Affiliated

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.

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Please read the options of the different reports to ensure you select the correct report.

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: Whitaker Hall, BIOL 101, etc.

Involved Parties

Please list all parties involved (excluding yourself) and provide as much information as possible in the demographic fields. If you do not have access to the demographic information, please continue to submit the report; the information will be researched once the report is received.

For an individual who is not a member of the HACC community, please list a driver's license number in the field labeled HACC ID Number (if available).

Roles in which the parties may be involved include the following:

Accused/Respondent/Referred Party: member of the HACC community who may have violated a HACC policy
Victim/Complainant/Referring Party: individual who experienced the alleged behavior
Witness: individual (excluding yourself) who observed the alleged behavior and can provide additional information
Other: individual who is not a member of the HACC community.

Name (First and Last)

Select Role

HACC ID

Phone number

Email address

Questions

Please provide a detailed description using specific, concise, objective language. Describe the specific behaviors observed, including words, phrases, and actions, and dates and times. If the involved party used profanity, made threats, or spoke of harming self or others, indicate specific words and phrases used. If the involved party was loud or disruptive, indicate any behaviors associated with the disruption, and describe any injury or damage to individuals or property. Include names of HACC personnel you contacted, and actions taken, if any. For readability, identify individuals in the description by last name.

Please provide a detailed description using specific, concise, objective language. (Who, what, when, why, and how)(Required) This field is required.

Is anyone involved in the incident a minor (under the age of 18)?(Required) This field is required.

If yes, please indicate the name of the person(s) below.(Required) This field is required.

Did you refer the student to Mazzitti & Sullivan Counseling Services?(Required)

Yes No

You must make at least one selection.

Did you refer the student to Student Access Services?(Required)

Yes No

You must make at least one selection.

Have you taken any actions to assist the student? Please indicate Yes or No. If you have taken action(s) to assist the student, please detail below.(Required) 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