ZSC Incident Report Form

Background Information

Note: If you wish to remain anonymous do not enter information into the Name or email fields.  However, If you do not leave contact information we will be unable to follow up on any resolution with you regarding this incident.

Incident Details

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 Drivers License number in the block labeled Student ID # if available.

Questions

Please provide as much information as possible. If there are questions you cannot answer or information you are uncomfortable sharing in this format, please state that in the appropriate field. Please provide a detailed description of the incident/concern using specific concise, objective language (who, what, where, when, why, and how). The use of direct quotes is encouraged, including profanity or abusive language that may have been used during the incident. If you have brought this matter to the attention of any department(s) at the college, please list the name(s) and department(s) of all persons with whom you have discussed the mater.
Type of Complaint

Describe your complaint. Please summarize below and attach additional pages describing your complaint if necessary. Please provide as many specific details as possible, such as the date, location, time of day, verbal statements made, pattern of behavior (if multiple incidents), etc.

I certify the aforementioned is true and correct to the best of my knowledge.
Behavioral Concens
Has a staff or faculty member corresponded with the person of concern?

Do you know of a person who is close with this person who could be contacted to assist in this concern? If yes, please describe the nature of their relationship (e.g. professor, roommate, friend, etc.) and provide any of their contact information you have in your possession.

Acknowledgement
I understand that referrals from this form are not monitored after hours, on weekends, or during official College holidays. If there is an immediate risk of harm to self or others dial 911 immediately prior to submitting this form.

Support Documentation

Photos, video, email, and other supporting documents may be attached below. 256 MB maximum total size. Attachments require time to upload, so please be patient after submitting this form.
Drag & Drop Files, Choose Files to Upload You can upload up to 5 files.
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