Roanoke-Chowan Community College Incident Reporting Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Roanoke-Chowan Community College (R-CCC) has an established Behavioral Assessment Team (BAT) to address any concerns with questionable, disturbing, confusing, or potentially threatening behaviors.

Please complete the following information as the individual filing the incident report. If you would like to remain anonymous, please place a "N/A" in the appropriate fields.

Reporter Name *

Reporter Position/title:

Reporter Phone number:

Reporter Email Address *

The Incident - Location on Campus

Description of the Incident

Additional Description

Date of the Incident

YYYY

Time of the Incident

Time

People Involved in the Incident

IDs of Involved Persons

Contact Information of Involved Persons

Description of Prior History, if applicable

Affected Persons' Names

IDs of Affected Persons

Contact Information of Affected Persons

Was there a Witness?

Yes

Clear selection

Names of Witnesses

IDs of Witnesses, if applicable

Contact Information of Witnesses

I certify that: *

By submitting this form, I agree that I understand R-CCC may be obligated to take measures to address potential violations of Title IX, R-CCC Code of Conduct, or other regulations as necessary. In addition, I understand that the College prohibits Retaliation against a reporting party and that if a reporting party makes a false accusation, the reporting party will be subject to appropriate disciplinary action.

Required

I certify that: *

I understand and agree.

Required

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report

Forms