CONDUCT INCIDENT REPORT

Vice President for Student Services or

Student Judicial Affairs Officer

Date:
Name of Student Being Referred: / SID #:
Address (if known): / Phone:
Your Name: Faculty Staff Administrator Student
Office/Division: / Ext: / Mail Stop: / Email:
Address: / Phone:
Reason(s) for referral:

What action are you seeking?

information and consultation disciplinary action referral for counseling or mediation services

Please check all that apply. For assistance, refer to Student Rights & Responsibilities Code, WAC 132L-120-080
For Academic Dishonesty, please complete a Report of Academic Dishonesty. See WAC 132I-120-080(5)
(5)(a) Assault, reckless endangerment, intimidation and interference.
(5)(b)Disorderly, abusive or bothersome conduct.
(5)(c) Inattentiveness, inability, or failure to follow instructions.
(5)(c) Refusal to comply with any lawful order to leave the college campus.
(5)(d) Illegal assembly, obstruction or disruption.
(5)(e) False complaint.
(5)(f)False alarms.
(5)(g)Sexual harassment including stalking
(5)(h)Racial harassment including: intimidation, overt threats, physical acts of aggression, demeaning racial jokes, demeaning graffiti
(5)(i)Furnishing false or imcomplete information to any College Official
(5)(j)Intinidation of witnesses
 / (5)(k)Destruction of Evidence
(5)(l)Sexual Assualt
(5)(m) Physical or emotional abuse of another student/staff/faculty
(5)(n)Harassement
(5)(o)Threat: Conduct intended to threaten bodily harm
(5)(p)Reckless conduct: creates substantial risk of physical harm to either one’s self or others
(5)(q)Incitment: engaging others in any unlawful activity
(5)(r)Undue noise: noise that interfers with College functions
(5)(s)Aiding or abetting misconduct:
(5)(t)Failure to cooperate with an investigation
(5)(u)Theft or robbery
(5)(v)Malicious mischief
(5)(w)Unauthorized use of College equipment and supplies
(5)(x)Unauthorized entry, access or presence upon the property of the College
(5)(y)Computer, telephone or electronic technology violation

Return this form to the Student Judicial Affairs Administrator, Student Center Building 101, Ext. 224

(5)(aa)Forgery, falsification or alteration of official College documents.
(5)(bb)Refusal to provide positive identification
(5)(cc)Smoking in classroom, laboratory, any College facility, or in no smoking areas
 / (5)(dd)Using, possessiong, delivery, selling or being under the influence of controlled substance without a valid perscription
(5)(ee)Possession or consumption of alcoholic beverages on college property or at a college sponsored event
(5)(ff) Violation of College policy
(5)(gg)Ethic Violation
(5)(hh)Hazing
(5)(ii)Initiation violation
(5)(jj)Prohibition of animals: No animals on campus exception of service animals
(5)(kk)Misuse of student identification
(5)(ll)Other misconduct
(5)(mm)Failure to comply with the following regulations governing firearms and weapons
(5)(nn)Gambling
(5)(oo)Lewd conduct
(5)(pp)Bicycling and skating
(5)(qq)skateboarding

Nature of complaint/problem (Describe the behavior or action of the student. Attach further documentation as necessary):

Prior action you have taken: In some cases, prior action may have been taken by a faculty or staff member. Please check any of the following points that have been addressed with the student. If statements have been delivered to the student in writing, please attach a copy to this report.

A specific description of the behavior

A statement that the behavior is disrupting the campus or classroom environment

A statement that the behavior must stop

A statement that further occurrences of the behavior will result in removal by the instructor from the class session

For Judicial Officer Use Only

For further information, contact the Student Judicial Affairs officer at (360)736-939110, Ext. 224

revised 09/17/12 skb