INCIDENT REPORTING FORM
Please use this form to file a concern with the Office of Student Affairs at Andrew College. Submission of this form initiates further inquiry of the issue and may lead to formal charges under the Student Code of Conduct. (If you have questions about this process prior to filing a concern, please contact the Office of Student Affairs at 229-732-5950.)

Examples of behaviors appropriate for this form include, but are not limited to:

*Violation of college policy
 or specific college directive

*Disruption of classroom or college activities
*Violation of an applicable law
*Physical assault

*Sexual misconduct, sexual assault, sexual harassment, stalking 

*Relationship abuse (verbal, physical, sexual, mental, etc.)
*Theft of property or services
*Threats

*Hazing

*Hate crimes
*Alcohol- and drug-related violations
*Intentional or reckless property damage 

*Falsifying a document

*Impersonating another
 person
*Computer violations






If you are considering filing a student concern related to sexual assault, sexual harassment, relationship violence, or stalking, we encourage you to contact Jennifer Mitchell, Deputy Title IX Coordinator and Compliance Officer, at 229-732-5946 or jennifermitchell@andrewcollege.edu.

In the narrative, please outline as much information about the concern as possible, including what happened, when and where the incident occurred, who was involved/has direct knowledge of the incident, the student(s) involved, how it came to your attention, and what steps have been taken thus far. (If you would like to submit an anonymous report, you may do so, but the college may be limited in the scope of the follow-up we can provide.)

Relevant materials may include written statements, photographs, police reports, and other records.

All information provided becomes an educational record and may be shared with the responding student if formal charges are filed, and may be used as documentation if the concern proceeds to a hearing. Confidentiality of educational records is outlined by the Federal Education Rights and Privacy Act (FERPA).

BACKGROUND INFORMATION
Your Full Name:
Or, you may write Anonymous
Your answer
Your position/ title:
Your answer
Your phone number:
Your answer
Your e-mail address:
Your answer
Your physical address:
Your answer
Nature of this report:
Urgency of this report:
Date of incident:
MM
/
DD
/
YYYY
Time of incident:
Time
:
Location of incident:
INVOLVED PARTIES
Please list the individuals involved (excluding yourself), including as many of the listed fields as you can provide. Please enter the student(s) Andrew College ID numbers, if available.
Name / Hall / Room # AND Role
Please include the any names, hall and room number of parties involved and their role such as accused, victim, and/or student of concern.
Your answer
Phone Number:
please include the phone number of any involved parties if known.
Your answer
Witnesses
Please include the any names, hall and room number of any witnesses.
Your answer
DESCRIPTION / NARRATIVE
Please provide a detailed/ specific description of the incident/concern using concise, objective language. If the incident occurred in the classroom or as part of a course, please list the course name.
Your answer
ADDITIONAL QUESTIONS
How did you become aware of the incident
Were you personally threatened?
Did you see others threatened?
Do you think others are uncomfortable due to the incident?
How was the incident terminated?
SUPPORTING DOCUMENTS
Please e-mail any photos, video, email, and/ or other supporting documents to jennifermitchell@andrewcollege.edu
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