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, including as many of the listed fields as you can provide. For non-students, please list a Driver's License number in the block labeled SID (BearPass ID#) if available.

Involved party 1

Name or Organization

Select Role

BearPass Number

DOB (YYYY-MM-DD)

Phone number

Email address

Hall/Address

Questions

Please indicate the relevant category/categories that pertain to this incident report.

Behavioral Intervention Team

Academic difficulties

Acts motivated by hatred or discrimination

Anxiety

Classroom disruption

Chronic stress

Depression

Disoriented Thinking/Expression

Disruption, other than classroom

Eating or body image concerns

Food insecurity/Hunger

Excessive class absenteeism

Financial Problems

Flat affect or extreme lack of responsiveness

General mental health concerns

Grief from Loss

Harassment

Hazing or bullying

Homeless

Hospitalization

Hygiene concerns

Interpersonal conflicts/ issues

Medical Concerns

Other

Paranoia

Relationship violence

Risky behaviors

Self-harm, observed or reported

Social isolation

Stalking

Substance use concerns

Suicide attempts

Suicidal ideation/threats

Threatening words or actions

Traumatic event

Writings that convey clear intentions to harm self or others

You must make at least one selection.

Student Conduct

Abuse of computing resources (4.18)

Abuse of the conduct system (4.21)

Acts of dishonesty (Non-Academic) - Forgery, alteration or misuse (4.1)

Acts of dishonesty (Non-Academic) - Furnishing false information (4.1)

Acts of dishonesty (Non-Academic) - Tampering (4.1)

Alcohol policy violation (4.11)

Attempted or actual damage to property (4.4)

Attempted or actual theft (4.4)

Disruption or obstruction of University activities (4.2)

Facilitating or encouraging a conduct violation (4.23)

Failure to Comply (4.6)

Failure to Comply - COVID Housing Directive (4.6)

Discriminatory Harassment (4.3)

Hazing (4.5)

Improper use of keys or unauthorized access (4.7)

Narcotics violation (4.10)

Narcotics violation (4.10) - Controlled Substance other than Marijuana

Narcotics violation (4.10) - intent to sell/ distribute

Narcotics violation (4.10) - paraphernalia

Disruption of normal operation (4.14)

Obstruction of pedestrian or vehicular traffic (4.15)

Physical Misconduct (4.19)

Sexual harassment and other forms of sexual misconduct (4.20)

Tampering with safety equipment (4.13)

Unauthorized fireworks, firearms, explosive weapons, and other weapons (4.12)

Unauthorized surveillance (4.16)

Unauthorized distribution of sexually explicit images, etc. (4.17)

Violation of laws/ordinances and/or off campus violations (4.9)

Violation of University policies, rules, or regulations (4.8)

Violation of University policies, rules, or regulations (4.8) - appliances

Violation of University policies, rules, or regulations (4.8) - candles

Violation of University policies, rules, or regulations (4.8) - courtesy hours

Violation of University policies, rules, or regulations (4.8) - escort

Violation of University policies, rules, or regulations (4.8) - hall ball

Violation of University policies, rules, or regulations (4.8) – lamp

Violation of University policies, rules, or regulations (4.8) - incense

Violation of University policies, rules, or regulations (4.8) - - residence life mask policy

Violation of University policies, rules, or regulations (4.8) - mask policy

Violation of University policies, rules, or regulations (4.8) - pets

Violation of University policies, rules, or regulations (4.8) – tapestry

Violation of University policies, rules, or regulations (4.8) - quiet hours

Violation of University policies, rules, or regulations (4.8) - solicitation

Violation of University policies, rules, or regulations (4.8) - visitation

Violations of Missouri State's Tobacco Use/Smoking Policy (4.21)

You must make at least one selection.

Please provide a detailed description of the incident/concern using specific concise, objective language (Who, what, where, when, why, and how). This field is required.

Was University Safety notified?(Required)

Yes No I don't know

This field is required.

If yes, what was the University Safety report number? This field is required.

Was the police notified?(Required)

Yes No I don't know

This field is required.

If yes, what was the police report number? This field is required.

Supporting Documentation

Please submit all supporting documentation as a pdf. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

Submission

Email me a copy of this report