GENERAL INFORMATION
Date:
Incident Location:
Time:
Nature of Incident:
REPORTING PARTY(S)
Name
Employment Position/Student
Extension
Local Phone Number
Email Address
Physical Address
Zip Code
City/ State
STUDENT(S) INVOLVED
Name
Date of Birth
Gender
Local Address
Contact #
Class
WITNESSESES/OTHER STUDENTS INVOLVED
Name
Date of Birth
Gender
Local Address
Contact #
Class
DETAILED DESCRIPTION OF INCIDENT OR CONCERN:
Terra State Community College
Behavioral Intervention Team
Incident Report Form 2019-2020
INCIDENT #:______________
Open Date:_______________
Closed Date:______________
Outcome:________________
Duration of Behavior:
Describe any action taken to address concern:
Please complete fully and email directly to the following email:
OFFICE USE ONLY
Nature of Incident:_____________________________________________________________________
Academic Performance/Behavior/Incident
Alcohol Violation
Underage_____
Other_____
Disorderly Conduct
Physical Altercation_____
Verbal Altercation _____
Property Damage _____
Quiet Hours Violation____
Non-Compliance _____
Drugs/Illegal Substances
Suspected_____
Possession/Misuse_____
Financial Issues_____
Fire Safety Violation
Fire Alarm_____
Active Fire_____
Personal Issues
Theft/Burglary_____
Sex and/or Gender Issues_____
Wellness Concerns
Injury_____
Wellness Issue_____
Mental Welfare / Health_____
Illness_____
Hospital Transport_____
Other Violation
Smoking in Residence Halls_____
Parking Lot Violation / Car Accident_____
Prohibited Items_____
Unknown_____ (Identify in notes)
URGENCY OF REPORT (please circle):
Information Sharing/ Not Urgent_____ Ongoing Concern____ Urgent Attention_____
Date Received:_________________________
Prior Concerns:_________________________
BIT Team Member Assigned:______________________
Meeting Date & Time:___________________________
Notes:
Assigned to:__________________________
Follow-Up:___________________________
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