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Behavior Incident Report Form
This Behavior Incident Report is designed to enable faculty, staff and students to voluntarily report “Red Flag Behaviors” that may raise concerns at CVCC.
An incident, in this context, is an event that does not warrant immediate intervention. In the event of an emergency that requires immediate intervention, call
Campus Police cell 434-841-2939 or use a call box located on campus. The Behavioral Incident Report will provide a mechanism for responding to incidents and
will reveal patterns of disruptive behavior. It will provide aggregate data on the nature and frequency of disruptions. This report provides a standardized method for
recording observation of troublesome behaviors and for alerting staff of potential concerns. In accordance with the CVCC Student Code of Conduct, information
provided in the Behavioral Incident Report may be considered in determining appropriate disciplinary actions with students.
Student information please enter as much information as possible (continued on back page)
Name__________________________________________________ EMPLID #_________________________________
Address__________________________________________________Phone___________________________________
Incident information: Date of incident__________________ Date form completed______________________________
Location of incident__________________________________ Time of incident (approximate) _____________________
*Name of person(s) reporting incident ______________________________________Phone _______________________
Email Address ____________________________________________________________________________________
Are you a __student, __employee __ or other (please explain) _______________________________________________
Names(s) of others involved__________________________________________________________________________
Please provide a detailed description of the incident, paying particular attention to the behaviors of the student.
Concrete, specific observations are most useful. Avoid providing judgments, assessments and opinions:
Please describe conversations you have had with the student and any action you have taken regarding this incident: Please submit completed form to Counseling or
Campus Police Department **Individuals are allowed to make anonymous reports, however if a name is not provided it may hamper the team’s ability to
seek follow up information that may be critical in determining an appropriate course of actions. If a name is provided the team will provide feedback
regarding actions taken. The person submitting this Behavior Incident Report may wish to discuss this with a counselor prior to submitting the report.