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Online
Incident Report Form |
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Person Reporting
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Name |
(required) |
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Position (RA/CA, Faculty, Staff,
Student, etc.) If Residence Life Staff, Please include
Hall or area. |
(required) |
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Address |
(required) |
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City, State, Zip |
(required) |
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Local Phone |
(required) |
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Email |
(required) |
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Individuals Involved - Please fill
out as much information as possible |
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Name (Last, First, MI) |
SID Number (if Known) |
Campus Address |
Phone Number |
EmailAddress or
Other Contact Information |
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2. |
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3. |
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4. |
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5. |
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6. |
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Incident Location |
(required) |
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Date |
(required)
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Time |
(required) |
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Have the police been notified? |
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Yes
No |
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If yes, Officer who responded
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Type of Incident:
(Check appropriate information) |
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Violation
of Code of Conduct |
Medical |
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Specify Codes
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Physical |
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Maintenance |
Noise |
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Suicide Gesture/Attempt |
Hospitalization |
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Psychological
Problems |
Other
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Incident Description
*required |
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Please describe the incident in as
much detail as possible. |
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Report Filing -Check all that apply
(must check one) |
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I am filing this report for information purposes, which may initiate the student
conduct process. |
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I am filing this report for the purpose of initiating the student
conduct process. |
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I am filing this report for the purpose of seeking assistance with the
resolution of a a dispute. I understand that appropriate action may be taken
by the university. |
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Please forward a copy of this report to the appropriate law enforcement
agency. |
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Agreement (Must Check) |
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By submitting this report I am stating that all information contained in the
report is true and correct to the best of my knowledge. Knowingly filing a
false report may lead to University and/or law enforcement actions.
Furthermore that I realize that the individuals
involved and I may be afforded
certain privacy rights under the the Family Educational Rights and Privacy
Act (FERPA) which establishes requirements regarding the privacy of student
records. These records include student conduct cases and reports. This act
was created to protect students' rights by ensuring they be permitted to
inspect their own educational records, and prohibiting school officials from
disclosing personally identifiable information contained in educational
records without written consent. By submitting this form I hereby wave this
right in regards to the incident that I am reporting. Waiving this
right is only for the purpose of adjudication of the reported incident
through the Arkansas State University student conduct system.
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