Report A Concern Or Incident Form - Big Bend Community College

If this is an emergency, call 911 immediately.

By sharing your concerns, you are helping to maintain a healthy and safe educational environment.

Please read the questions carefully and respond as thoroughly as possible.

Use this form to report violations of the Big Bend Community College Student Code of Conduct or to report distressing and/or disturbing student behavior.

Background Information:

Please provide as much detail as possible. Starred items are required. By completing this form, you are confirming that all the information is true to the best of your knowledge.

Your Name:

Your email address:

Your physical address:

What are you reporting?

Your position/title:

Your phone number:

Date of incident

Time of incident

Location of incident:

Student of Concern:

Please provide as much information as possible about the person(s) involved in this situation. Besides the student you're reporting, please be sure to include any witnesses, victims, and anyone else impacted by the incident. Do not include yourself. Please leave any boxes that you are unsure about, blank.

Full Name:

Address

DOB

Email Address

Nature of Involvement:

Phone Number

Information

Describe the Incident or Concern:

The following section includes quick-response questions, as well as a section that you can use to describe the incident or concern further. Please describe the incident or concern; include behaviors that occurred and any actions you took.

Please choose all that apply:

General concern (describe below)

Essential needs not met (food, shelter, etc.)

Deterioration in quality of academic performance

Repeated absences/tardiness coupled with signs of distress

Change in demeanor, hygiene, or appearance

Self-mutilation (noticeable cuts or burns)

Supporting Documentation:

This may include emails, handwritten notes, plagiarized papers, etc.

Choose files to upload

The information you provided may become part of the student’s educational record. Educational records are protected under the Family Educational Rights and Privacy Act of 1974 (FERPA). Questions regarding FERPA and student records may be directed to the Director of Enrollment Services at 509.793.2065