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 ofce 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
EDU 230 9/10
BART Concern/Incident Report p2
Please describe the concern/incident.
Please explain the level of your reaction to the concern/incident (threa tened, uncomfortable, harassed, etc.)
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