Behavior Reporting Form - Incident Report

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 who you are reporting. If you are reporting a conduct issue, the "role" (third drop-down box) is ALLEGED. If you are reporting a concern about the individual(s), please mark it as STUDENT OF CONCERN. Thank you.

Name or Organization

Select Role

ID Number

DOB (YYYY-MM-DD)

Phone number

Email address

Questions

Please indicate the relevant category(s) that pertain to this report. This field is required.

A CONCERN ABOUT A STUDENT

Alleged Domestic Violence Off Campus

Behavior Concern

Drug or Alcohol Abuse

Personal Issues

Poor hygiene

Possible threat to self

Unusual behavior or atypical behavior

Unusual Frustration or Anger

You must make at least one selection.

ACADEMIC

Academic Misconduct

Violation of Program Rules

Vocational Program Violation

You must make at least one selection.

ACADEMIC ALERT

Attendance Issue - No Longer Attending

Desire-2-Learn or Computer Issue

Needs Tutoring

Other

Poor Participation

You must make at least one selection.

APPEAL

Disciplinary Appeal

You must make at least one selection.

COMPLAINTS

Academic complaint

Activity Complaint

Complaint - Financial Aid

Complaint - Fiscal

Department Complaint

Personal Complaint

You must make at least one selection.

READMISSION

Readmission after Expulsion

Readmission after Suspension - Academic Misconduct

Readmission after Suspension - Behavior other than Drugs

Readmission after Suspension - Drug Violation

You must make at least one selection.

TITLE IX

Dating Violence

Domestic Violence

Harassment

Retaliation

Sexual Assault

Sexual Misconduct

Stalking

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.

Please list any witnesses or others who may have information related to this report. This field is required.

Please list anyone who was a victim of the actions of the person who is being reported. This field is required.

I wish to remain anonymous in submitting this report. (NOTE: requests to remain anonymous in reporting alleged violations of the PCC Student Code of Conduct will severely hamper any College investigation and can result in the College being able to take little or no action.) This field is required.

If applicable, the victim of the actions reported here wishes to remain anonymous. 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