Fillable Lpc Student Incident Form-editable 050714rev Office of Student Affairs

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Lpc Student Incident Form-editable 050714rev Office of Student Affairs

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Las Positas College
Office of Student Services
Student Incident Report
Reporting Procedures:
1.
Complete this form
2.
Submit the completed form
to the Campus Safety
Department by hand delivery
or fax (925)371-0283.
Use this form to refer issues to Campus Safety and the BIRT. For more information, please call Sean Prather @ (925)424-1690 or Julie
Thornburg (925) 424-1406 for more information.
EMERGENCY: If student is a threat or help is needed immediately, call 9-1-1 or Safety @ 925-424-1699
GENERAL INFORMATION
Student’s Last Name:
First:
Student ID:
Address:
Email:
Phone:
Name of Person Submitting Report:
Contact Info:
Date & Time of Incident/Infraction:
Location:
EMERGENCY STUDENT ISSUES OR CONCERNS CONTACT SAFETY IMMEDIATELY 925-424-1699
DISORDERLY, LEWD, INDECENT, OBSCENE, OR OFFENSIVE CONDUCT OR EXPRESSION
ASSAULT/BATTERY, ABUSE, OR ANY THREAT OF FORCE OR VIOLENCE
POSSESSION/USE OF FIREARMS, EXPLOSIVES OR OTHER WEAPONS
POSSESSION OF ANY ARTICLE AS A WEAPON TO THREATEN BODILY HARM
USE, POSSESSION, DISTRIBUTION OF ALCOHOL OR DRUGS OR VIOLATION OF SMOKING
POLICY
NON EMERGENCY STUDENT ISSUE OR CONCERN (CHECK ALL THAT APPLY)
Willful disobedience or defiance
toward college official
Theft/damage to, property belonging to the college & college
community
Obstruction or disruption of
College day-to-day operations
Misuse of College information technology equipment/software/internet
access
Individual presents with a significant risk of danger to self, danger to others, and/or grave disability (provide
specifics below)
Other: (Explain)
DESCRIPTION OF INCIDENT OR BEHAVIOR (use additional sheets if necessary):
FACULTY, STAFF OR STUDENT WHO OBSERVED THIS INCIDENT (please include name and contact
1.
PRIOR ACTION(S) TAKEN BY FACULTY/STAFF MEMBER
Warning Issued for Offense: Verbal Written
Removal from Class: Date(s)
_____________________
Other Action(s):
Additional
Info
FOLLOW-UP ACTION REQUESTED (check all that apply) This report is for information only.
This referral is for your information
only. No follow-up requested
Please call with suggested interventions
Please meet with student for
disciplinary action
Other: (Explain)
_______________________________
ADMINISTRATIVE ACTION (description of actions taken)
ADMINISTRATOR’S SIGNATURE: ____________________________________DATE: _____________________________
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Lpc Student Incident Form-editable 050714rev Office of Student Affairs

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Completed 16 November 2019

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