Incident Report Form

Incident Information

Your full name (Required):

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Or, you may write Anonymous

Your position/title:

Your phone number:

Your email address (Required):

Email address must be of a valid format.

Nature of this report(Required):

This field is required.

Urgency of this report(Required):

This field is required.

Date of incident(Required):

This field is required.

Time of incident:

Location of incident(Required):

This field is required.

Specific location:

Involved Parties

Please list ONLY the alleged offender(s), victim(s), and students/ guests of concern involved in this space provided below. Complete as many of the listed fields as you can provide. Student ID Numbers are essential. For non-students, please list an SSN or Driver License number. If these are unavailable, please write "unknown" in the block labeled 'ID Number.'

Name or Organization

Select Gender

Select Role

ID Number

DOB (YYYY-MM-DD)

Phone number

Email address

Address

Tell Us About Your Concerns

Please provide a detailed description of the incident/concern using specific concise, objective language (Who, what, where, when, why, and how).(Required) This field is required.

For Report of Student Misconduct, please list course/section number and which Standard of Conduct was violated. Student Standards of Conduct can be found in SWC Administrative Procedure 5500. This field is required.

For Reports of Student Misconduct, Reports of Student Grievance, and Reports of Academic Dishonesty, please describe a summary of actions you have already taken to attempt to resolve the issue and what resulted from those actions. Examples: I discussed the issue with the student; Instructional Dean discussed issue with student; I discussed the issue with instructor, etc.(Required) This field is required.

For Report of Student Grievance, please describe the resolution, corrective action, or remedy sought.(Required) This field is required.

What are you hoping to achieve by filing this report (e.g.: 'I need to know about resources to share with the student' OR 'I need Student Affairs to address the conduct concern')? Please note any concerns you have for you own well being and if you would like us to reach out to provide you support.(Required) This field is required.

Please list all OTHER parties involved in the incident (e.g.: witnesses, campus police, faculty) below. Alleged offender(s), victim(s), and/or student(s)/guest(s) of concern should be noted in the appropriate spaces above. For all other involved parties, list their full names, titles (and student ID# if applicable), and note their involvement in the incident. For example: "Jane Doe, student (ID # 123456789), Witness" or "John Doe, Southwestern College Police Officer, Responding Officer." This field is required.

Was College Police or another law enforcement agency involved or notified?(Required)

Yes No I don't know

You must make at least one selection.

Supporting Documentation

You may attach photos, copies of emails, assignments, or any other documents that support your reported concern.
If you are submitting a Formal Report of Academic Dishonesty, please submit supporting documentation, including e-mails or notifications to the student regarding the issue. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

Email me a copy of this report

Incident Information

Involved Parties

Tell Us About Your Concerns

Supporting Documentation

Submission