Labette Community College

Incident Reporting Form

Background Information

Your full name:  Or, you may enter Anonymous
Your position/title:
Your phone number:
Your email address:   Email me a copy of this report
Your physical address:
* Nature of this report:
Urgency of this report:
*Date of incident:
Time of incident:
*Specific location:

Reason(s) for Report

Please indicate the relevant category/categories that pertain to this incident report.

ACADEMIC MISCONDUCT

Academic Dishonesty
Classroom Disruption
Grade Appeal

CARE: CONCERNING OR THREATENING BEHAVIOR

Acting Out
Agressive Behavior
Alarming Infatuation with Fire or Firearms
Alarming References to Bombs/Ammunition


























NON-ACADEMIC MISCONDUCT


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STUDENT RIGHTS AND RESPONSIBILITIES










Involved Parties

Please list the individuals involved (excluding yourself), including as many of the listed fields as you can provide. For non-students, please list a SSN or Drivers License number if available.

Person 1
Name
Gender
 Role
 ID Number
DOB (YYYY-MM-DD) Phone Number Email Address Address

Person 2
Name
Gender
 Role
 ID Number
DOB (YYYY-MM-DD) Phone Number Email Address Address

Description / Narrative

Please provide a detailed description of the incident/concern using specific concise, objective language (Who, what, where, when, why, and how). If this report is for academic dishonesty, please include course/section number and assignment name (quiz, test, essay).