Behavioral Incident (HEAT) Report

Background Information

Please provide the following information to ensure that Harper College can respond and follow up on this report. Please be advised that if you provide an anonymous referral, there may be limits to the College's ability to adequately investigate and/or address the situation.

If you have concerns or questions, please call 847-925-6898 or email the HEAT team

Your Full Name:

Your Position/Title/Role:

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 Response Requested(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/Room/Course:

Person(s) Involved

Please provide any known contact information about the individual(s) involved in the incident. You may report a concern about any person - student, staff, faculty, alumni, parent, community member, etc. Please provide as much information as possible. If you do not know all of the details, just include what you do know. Please ensure that you have spelled names correctly and that any Harper ID numbers are correct. You do not need to include your name/information as the reporting party as you have already provided your information above.

Name

Perceived Gender

Role

Harper ID Number (if known) of Person Being Referred

DOB (YYYY-MM-DD)

Phone Number

Email Address

Home/Campus Address

Summary of Incident & Questions

Please answer the following questions based on what you have observed or what has been reported to you. Please provide as much detailed information as you can about what happened.

What is the purpose of this report? (Check all that apply)(Required)

I am concerned about a possible threat of physical violence and would like a threat assessment completed by HEAT. I am concerned about someone, but not because of potential violence. I want to report a possible policy violation to initiate a campus investigation/the campus conduct process. I am just reporting this so that the College is aware of it - I am not necessarily requesting action be taken. I am not sure.

You must make at least one selection.

What happened? Please describe the concern, incident, and/or behavior(s) that you observed.(Required) This field is required.

What were the impacts of the behavior or incident? How were others affected? Describe any effects on the learning environment, damages to property, or disruption experienced by others.(Required) This field is required.

Were there any attempts to intervene or confront the individual? Why or why not? How were those attempts received by the individual?(Required) This field is required.

Please provide the names of any witnesses or other persons who might have information related to this incident. This field is required.

Is there anything else you would like to add? This field is required.

By submitting this report, you are acknowledging that the information provided may be viewed by the appropriate College officials. The information will also be maintained in accordance with applicable college record keeping practices. (This includes the Family Educational Rights and Privacy Act (FERPA), which means that if information contained in this report leads to a formal student conduct process, the student(s) whose behavior is in question has the right to review the relevant content.)(Required)

I agree.

You must make at least one selection.

Supporting/Related 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

Person(s) Involved

Summary of Incident & Questions

Supporting/Related Documentation

Submission