Student Conduct Referral

Background Information

Your full name:

Your position/title:

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Examples include: Student, Harper Staff, Harper Faculty, Non-Student, Community Member, etc.

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):

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Date of incident(Required):

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Time of incident:

Location of incident(Required):

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Specific location:

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(Provide additional details about location if known)

Involved Parties

Please provide any known contact information about the individual as well as any witnesses or affected persons., including yourself. Please provide as much information about the person as possible. If you do not know all of the details, just include what you do know.

Name or Organization

Select Gender

Select Role

ID Number

DOB (YYYY-MM-DD)

Phone number

Email address

Address

Questions

Please provide a detailed description of the incident/concern using specific concise, objective language (Who, what, where, when, why, and how). Please include information about the effects of the individual's behavior, as well as any attempts to intervene or address the behavior(s) of concern, but refrain from speculation or judgment about the individual. This field is required.

What were the effects of the individual's actions/behaviors? Describe any impacts to other people, disruption to the learning environment, or damages that may have occurred. Be as specific as possible.(Required) This field is required.

If any attempts were made by you or others to intervene, address, or mitigate the behavior, please describe those. This field is required.

How did the individual respond to those attempts? This field is required.

I understand that this complaint is subject to the Family Educational Rights and Privacy Act (FERPA) and that it may be accessed by the person who is the subject of this report; as well as those College officials with a legitimate educational interest in the information. I also understand that the College does not tolerate retaliation in the conduct process, and I can report any retaliation to Student Conduct and/or Harper College Police.(Required)

I agree

You must make at least one selection.

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