EDU 230 9/10
Behavioral Assessment Review Team
BART Concern/Incident Report
Date Name of person ling out report
Day Phone # Evening Phone #
I am a student. My home campus is: AH HL OR RO SF
I am a staff/faculty member at: AH HL OR RO SF DO PC
I am a community member.
This concern/incident is regarding a student.
Student’s First Name
Student’s Last Name
Student’s ID Number (if known)
Student was enrolled at the time of the concern/incident.
Yes No
This is regarding a non-student. (Name or description of the non-student)
Please ll out the following about the concern/incident.
Date of the concern/incident
Semester when the concern/incident happened
Campus where the concern/incident occurred
Building and/or room where concern/incident occurred
Department or ofce involved in the concern/incident
If the concern/incident involved a particular class, please complete the following.
Course number and name
Meeting time of the course
Meeting days of the course
Name of the instructor
Check here if you would like to be contacted to discuss the concern/incident.
Please use the reverse side of this form to describe the concern/incident and your level of reaction.
When completed, submit the form to any campus Dean.
OVER
