Student Services Administration
PERSONAL MISCONDUCT REPORTING FORM
Send all information to Vice Chancellor of Student Affairs (Savannah Center 226). The Vice Chancellor will forward a copy of this report to the Dean of student(s)’s School. Retain a copy of everything you send.
Date of Report__________________
Name of Student:___________________________________________ID# (optional): ________________
Date of Incident:_______________________________________Time of Incident: ___________am/pm
Location of Incident: (Street, Building) _________________________________________________
Or (Dept., Course Number, Section) ___________________________________________
Type of Incident:
___Abuse (Physical, Verbal) ___Alcohol or Drugs ___Arson ___Computer Misuse ___Disorderly Conduct
___Failure to Comply ___Forgery or False Info. ___Harassment ___Lewd or Indecent ___Phone Misuse
___Sexual Assault/Rape ___Weapons or Explosives ___Theft ___Unauthorized Use ___Vandalism
Summary of Incident: (Please attach a detailed summary of the incident.)
Did the student threaten you or others? ___________Yes __________No
If so, what was said or occurred? ___________________________________________________________________
______________________________________________________________________________________________
Witnesses to the Incident: 1. Name_________________________________Phone Number________________
2. Name_________________________________Phone Number________________
Reported by (print your name):____________________________________________________________________
Signature: _____________________________________________________________________________________
Your Department:_____________________________ Your Campus Address:____________________________
Your Campus Phone Number:_______________________________
The Code of Student Right Responsibilities, and Conduct, June 24, 2005 edition, may be obtained by contacting the Office of Student Life, 219-980-6746. , or obtain a copy from the web at http://campuslife.indiana.edu/Code/index.html