Behavioral Incident Reporting Form

Background Information

Disclaimer

Upon completion and submission, this form or information contained therein may constitute an education record of any student(s) referenced, and is protected from disclosure except in some limited circumstances. As an education record of a student, that student may have a right to review the form. The University will endeavor to maintain the information contained in the form as private, to the extent required and allowed by law. Questions regarding the form and its completion or use should be addressed to (dossaa@lsu.edu).

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Your full name:

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Or, you may write Anonymous

Your position/title:

Your phone number:

Your email address:

Email address must be of a valid format.

Your College/Department at LSU:

Date of incident(Required):

This field is required.

Time of incident:

Location of incident(Required):

This field is required.

Specific location:

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Please list specific room numbers or other physical descriptions.

Involved Parties

Please list the individuals involved, including as many of the listed fields as you can provide.

Name or Student Organization

89# (no dashes)

Phone number

Email address

Incident Description

Supporting Documentation

Please upload any information that supports this report. Supporting documentation may include pictures, screen shots, reports, emails etc. 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

Incident Description

Supporting Documentation

Submission