For OSCG use only: Date rec’d:_______ Staff: ______
SCC: _________________ CS ___ ST ___ ID __ CIF ___ PR ___
Revised8/18/2014
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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:
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Student ID:
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Term (e.g. Fall 2014):
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Course (e.g. Math 115) & Section:
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Today’s Date:
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Date and Time of Incident:
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Location of Incident:
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Reporting Party Name:
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Cerritos College Email Address:
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Reporting Party Preferred Contact Phone #:
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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.
