Coastline College Reporting Form

Background Information

Please use this form to submit a report related to any of the following:

-Student Conduct Violation (including academic misconduct)

-Sexual Misconduct (Title IX)

-Student Assistance Referral

-Behavioral Assessment Team (BAT) Referral

-Mental Health Referral-use this form (copy and paste this link): https://dynamicforms.ngwebsolutions.com/Submit/Start/63a31938-1451-4617-891b-3657aa9994de?SSO=N

If this is a life threatening emergency, please call 911.

If this incident involves an injury or poses an immediate threat of harm to any person, please contact Campus Public Safety at (714) 241-6040.

While anonymous reports are accepted, you are STRONGLY encouraged to provide your name and contact information so we can most effectively address the matter. Not knowing the identity of the reporter can make it more difficult to assess and address the situation you've reported as we are unable to contact you for more information.

Your full name:

Your phone number:

Your email address:

Email address must be of a valid format.

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

Name

Gender

Select Role

Student ID Number

Phone number (if available)

Email address (if available)

Questions

Please provide a detailed description of the incident/concern using specific, concise, objective language (who, what, where, when, why, and how) written in the third person. Please submit supporting documentation below.(Required) This field is required.

If the incident is course related, please list the course name and number.(If not course related, reply below as NA)(Required) This field is required.

If you wish this report is a Behavioral Assessment Team (BAT) Referral (Concerning Behaviors)/Student Assistance, is the student aware that a report is being submitted on their behalf? If this is not a Behavioral Assessment Team (BAT) Referral (Concerning Behaviors)/Student Assistance Report, reply below as NA.(Required)

Yes No N/A

This field is required.

If the nature of this report is a Behavioral Assessment Team (BAT) Referral (Concerning Behaviors)/Student Assistance, please indicate any referrals you made to the student. (i.e. I referred the student to the food pantry, I referred the student to counseling, etc.) If this is not a Behavioral Assessment Team (BAT) Referral (Concerning Behaviors)/Student Assistance Report, reply below as NA.(Required) This field is required.

If the nature of this report is a Behavioral Assessment Team (BAT) Referral (Concerning Behaviors)/Student Assistance, what actions are you hoping will be taken? (i.e. I want to alert the Dean of Students, I am seeking resources related to a specific topic, I would like someone to reach out directly to the student, etc.) If this is not a Behavioral Assessment Team (BAT) Referral (Concerning Behaviors)/Student Assistance Report, reply below as NA.(Required) This field is required.

Supporting Documentation

For all incidents involving academic dishonesty please provide supporting documents (i.e., syllabus, student assignment, student communications, etc.). PDF-format preferred 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