For OSCG use only: Date rec’d:_______ Staff: ______
SCC: _________________ CS ___ ST ___ ID __ CIF ___ PR ___
Revised 8/18/2014
Reason for Referral/Description of Incident - Please provide a detailed description of the
incident, including any disciplinary action taken by you (removal from class, written reprimand).
Please include any prior incidents and actions. Please complete this form and forward to the
Dean of Student Services in the Office of Student Activities. You may submit this form via e-mail
at Conduct@Cerritos.edu. You may attach additional sheets, if necessary, and any related
documentation.
Student First & Last Name:
___________________________________________
Student ID:
___________________________________________
Term (e.g. Fall 2014):
___________________________________________
Course (e.g. Math 115) & Section:
___________________________________________
Today’s Date:
___________________________________________
Date and Time of Incident:
___________________________________________
Location of Incident:
___________________________________________
Reporting Party Name:
___________________________________________
Cerritos College Email Address:
___________________________________________
Reporting Party Preferred Contact Phone #:
___________________________________________
In the event of an emergency, please contact Campus Police immediately at 562.860.2451
Ext. 2325, or call 911. If you detect a pattern of noticeable behavioral changes that you
think may lead to deeper issues in a student’s personal and academic life, please com-
plete the separate CAIR Crisis Intervention Form instead.
