UPDATED: June 11, 2019
Violation of Student Code of Conduct Report Form
For faculty, staff or students to report an incident in which they believe a student violated the RPCC Student
Code of Conduct. (Related Policy: Student Code of Conduct, found in 2019-2020 Catalog).
Reporter’s Information
Reporter’s Name: ___________________________ Lola Number: _____________________________
Phone Number: __________________ Email Address: _____________________________
I am a (check one): Faculty Member Staff Member Student
Incident Information
Place of Incident: _____________________________________________________________________
Date of Incident: ____________________ Approximate Time of Incident: _____ am/pm
Student Information
Name of Student: __________________________ Lola Number (if known): __________________
Email address of student (if known): _______________________________________________________
Phone number of student (if known): _______________________________________________________
UPDATED: June 11, 2019
Summary of Incident (attach additional pages if needed)
Routing Instructions
Completed forms can be either:
1. Printed and delivered to the Student Services Office at the Gonzales, Reserve, or Westside Campus; or
2. Emailed to CSAO@rpcc.edu
For Office Use Only (if report is hand delivered):
ate Received: __________________ Received By: _________________________
his form must be given to the Chief Student Affairs Officer.