Draft 02/10/12
Student Behavior/Incident Report Form
The purpose of the Student Behavior/Incident Report form is to document any behaviors or incidents on
campus that warrants disciplinary action or any behavior that is of concern. This may include violence,
threats of violence, inappropriate contact with the teacher or other students, or inappropriate written
assignments that reference violence toward anyone. This form is not mandatory, but allows individuals
involved in the incident the option to provide additional information regarding the event. Reports for
on-campus and extension site incidents should be submitted to the Associate Vice President for Student
Services. Incidents at the Ottawa Center can be provided to the OC Coordinator, who will communicate
with the Associate Vice President.
In the case of an emergency, always call 911. For urgent, non-emergency situations, call Campus
Security at x314.
Date of the Incident: _________Time of the Incident: _______ Location: __________________________
Name of Individual(s) Involved:
Name: __________________________________Name: ______________________________________
ID # and DOB_____________________________ ID # and DOB:_________________________________
Address: ________________________________ Address: ____________________________________
________________________________________ ___________________________________________
Phone #: ________________________________ Phone #: ____________________________________
**If the student is not an IVCC student, please get their address.
Description of the Incident: Provide a brief, concise description. Additional space is available on the back
of the form if necessary.
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Any other staff members/employees/security personnel assisting with or witnessing the incident:
____________________________________________________________________________________