Referral Form

This Behavioral Incident Report is designed to enable faculty, staff and students to voluntarily report “red flag” behaviors that may raise concerns and incidents of student misconduct at Lake Land College. An incident, in this context, is an event that does not warrant immediate intervention. In the event of an emergency or crisis situation that requires immediate intervention, call 911. The Behavioral Incident Report will provide a mechanism for responding to individual incidents and will reveal patterns of disruptive behavior of specific students. It will also provide aggregate data on the nature and frequency of disruptions at Lake Land College. This report provides a standardized method for recording observations of troublesome behaviors and for alerting staff of potential concerns. In accordance with the Student Code of Conduct and Disciplinary Procedures, information provided in the Behavioral Incident Report may also be considered in determining appropriate disciplinary action with students.

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*Required fields are denoted by an asterisk (*)

Student Information

Name (For multiple students, list one name and the rest in the comments)

Student ID

Incident Information

Date of incident

Date form completed

Class/Location of incident

Time of incident (approximately)

Name of person reporting incident

Phone

Email address

Are you a:
Student Employee Other
If other please explain

Names of other witnesses

Please provide a description of the incident, paying particular attention to the behaviors of the student. Concrete, specific observations are most useful. Avoid providing judgments, assessments and opinions:

Please describe the conversation you had with the student and any action you have taken regarding this incident.


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