Student Behavior Incident Reporting Form
The purpose of the Student Behavior Incident Reporting form is to document any behaviors or incidents on campus that
warrants disciplinary action or any behavior that is of concern. This may include violence, threats of violence,
inappropriate contact with the teacher or other students, or inappropriate written assignments that reference violence
toward anyone. This form is not mandatory, but allows individuals involved in the incident the option to provide
additional information regarding the event. Reports for on-campus and extension site incidents should be submitted to
the Vice President for Student Services. Incidents at the Ottawa Center can be provided to the OC Coordinator, who will
communicate with the Vice President.
In the case of an emergency, always call 911. For urgent, non-emergency situations, call Campus Security at x314.
Date of the Incident: _________ Time of the Incident:________ Location: _______________________
Name of Individual(s) Involved:
Name: ____________________________
ID # and DOB: ______________________
Address: __________________________
Phone #: __________________________
Name: _____________________________
ID # and DOB: _______________________
Address: ___________________________
Phone #: ___________________________
**If the student is not an IVCC student, please get their address.
Description of the Incident: Provide a brief, concise description.
Any other staff members/employees/security personnel assisting with or witnessing the incident:
Description of the action taken by the employee(s): ___________________________________________________
Submitted by:_____________________ Signature: _________________________________________
Additional information regarding the incident if necessary:
Contact phone number:
********************************Office Use Only ****************************************
Action taken: _________________________________________________________________________________
Other relevant information: _____________________________________________________________________
Signature:___________________________ Date: ___________________________________________
Position:____________________________ Contact phone: ___________________________________
8/6/19
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