Southwestern Oregon Community College Incident/Concern/Complaint Reporting Form

Background Information

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Your full name:

Your position/title:

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Student, Staff, Faculty, Community Member

Your phone number:

Your email address:

Email address must be of a valid format.

Your physical address:

Reporting to(Required):

This field is required.

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Who do you want your report to

Type of Report(Required):

This field is required.

Date(Required):

This field is required.

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Date when the Incident/Concern/Complaint took place

Time:

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Time when the Incident/Concern/Complaint took place

Location(Required):

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Location where the Incident/Concern/Complaint took place

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 a Driver's License number in the block labeled ID number if available.
Students, staff, and faculty please list your campus ID number in the block labeled ID number.

Please use the following definitions for the role of the involved parties:

Respondent: An individual that is alleged of behavior that may be considered a policy/code violation.
Complainant: Any individual that was directly targeted/impacted by alleged behavior that may be considered a policy/code violation.
Witness: An individual that witnessed the incident first-hand, but is not alleged of violating policy or directly impacted/targeted by analleged policy violation.
Reporting Party: Any individual that is reporting an incident, but did not directly witness it nor was directly targeted by it.
Person of Concern: Any individual that is exhibiting concerning behaviors or expressing concerns to you that are not related to alleged policy violations. This includes mental health, severe academic concerns, medical/health concerns, or family concerns.

Name or Organization

Select Role

ID Number

DOB (YYYY-MM-DD)

Phone number

Email address

Questions

Please consult the complaint process section of the Accessible Education Services site for more information regarding Americans with Disabilities Act (ADA) Section 504 complaints.

Do you want to submit this as a formal Americans with Disabilities Act (ADA) Section 504 complaint?

Yes No

This field is required.

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

Was SWOCC Campus Security notified?(Required)

Yes No

This field is required.

Was anyone transported by emergency services (ambulance, police, other)?(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