Student Conduct, Rights, and Responsibilities
Student Incident Report (non-academic)
This form is intended to be used when a student wishes to notify Student Conduct, Rights, and
Responsibilities regarding behavior which has had an adverse impact on them. Students wishing to file a
formal Discrimination, Harassment, Retaliation, or Sexual Misconduct complaint may do so at any time,
with the campus Title IX office.
Please note: Incidents involving staff, faculty, or administrators related to official actions, such as
academic or departmental decisions or actions, should be reported on the Notice of Inquiry form.
Today’s Date: ____
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Your Name: __________________________________ Student ID#: ____________________
Email Address: ________________________________ Phone Number: __________________
Complaint is against:
Name (if known): ______________________________________________________________
Relationship to you: ____________________________________________________
Contact Information (if known): ____________________________________________________
Date of Incident/Action: ______ /_____ /______
Description of Incident/Action:
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What are you seeking?
Resources and information
SCRR to contact offending student/possible discipline
Other
Please note: Information regarding this incident may be shared with and/or released to authorized
campus individuals with an educational need to know, as deemed appropriate by this office.
Student Signatur
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