Academic Disruption Incident Report Form (Page 2 of 2) in pdf

Academic Disruption Incident Report Form Page 2

Page 2 of 2

Action taken to date: (if any taken by incident reporter)

University Police Involvement: ____ NO

____ YES Case#:____________________

Recommended course of action and reasons for recommendation (for academic area only,

not SRR):

For Faculty/Staff: Due to FERPA regulations, the University can only disclose certain

information regarding conduct cases. Based on these regulations, the Student Affairs Office will

notify any instructors who have an educational need to know if a student of theirs has been

suspended or expelled from the university.

____________________________________________________________________

Reporting Person’s Signature

Date of report

NOTE: Within 48 hours of the incident, please send hard copy of this report to a.) the

department chair, b.) the Assistant/Associate Dean of the college, c.) the Office of Student

Rights and Responsibilities or the institution’s designated office in Student Affairs, and d.)

the student.

Academic Disruption Incident Report Form Page 2