Student of Concern Reporting Form
Kapi'olani Community College (KCC) cares about you. Are you worried about a student? Did you see something questionable? Are you experiencing discrimination? Tell someone!

KCC offers resources and support to all community members experiencing concerns related to student conduct, any act of discrimination, sexual misconduct, stalking, and dating/domestic violence, etc. If you would like to talk to someone directly, please contact the Vice Chancellor for Student Affairs/Title IX Coordinator at kapvcsa@hawaii.edu or (808) 734-9522. You should call Campus Security if the incident has reached a level of crisis. If you are ever unsure, call 734-9900.

We encourage you to make us aware of these concerns so that we can offer support and resources to you and/or those involved. KCC strongly encourages faculty, staff, and students to communicate concerning or problematic behaviors, which may or may not be considered a crisis situation, including:

DISCRIMINATION: Being treated differently due to person's identity? (i.e. being treated unfairly, campus climate issues, etc.)

SEXUAL MISCONDUCT: Aware of unwanted or abusive behavior? (i.e. domestic violence, sexual harassment, etc.)

DISRUPTIVE BEHAVIOR: Witnessing actions that violate school policy? (i.e. inappropriate behavior, theft, vandalism, etc.)

WELL BEING: Worried about the safety and health of a student? (i.e. behavior changes, threats of self-harm, etc.)

Please fill the form below so we may follow up on any incidences. Thank you for caring about our KCC community!

Background Information
This is typically the person that is making the complaint, you maybe the one making the submission. Please include as much information as possible.
Today's Date
MM
/
DD
/
YYYY
Your Full Name
Complainant or person making referral
Your answer
Your Email address
(if applicable)
Your answer
Department
(if applicable)
Your answer
Your Phone Number
Your answer
Your KapCC Status
Nature of this report
Indicate why you are filing this report
What is this concerning?
Urgency of this report:
Parties Involved
Please include as much information as possible of the person involved. If information is unknown, please leave blank.
Name of 1st party involved
Your answer
Choose one
KapCC Status
Name of 2nd party involved, if known
Your answer
Choose one
KapCC Status
Reason(s) for the Report
Please indicate any relevant category(s) that pertain to this report and also provide a description below.
ACADEMIC
Please select one, if applicable.
CODE OF CONDUCT
Please select one, if applicable.
CONCERNING BEHAVIOR
Please select one, if applicable.
HARASSMENT / DISCRIMINATION / RETALIATION
Please select one, if applicable.
Description / Narrative
Please provide a detailed description of the incident/concern using specific concise, objective language (Who, what, where, when, why, and how).
Your answer
Were there any witnesses present for the alleged behavior?
If yes, please list names and contact information:
(including phone number, address, student number (if applicable), email, etc.)
Your answer
If alleging harassment, did you take any action to stop the harassment?
If yes, please summarize the action taken:
Your answer
Other than this report, did you ever report the alleged discriminatory behavior to an employee of Kapi'olani Community College?
If yes, please state the name of the employee and the date you reported it to them:
Your answer
How would you like to see this situation resolved?
Your answer
Submit
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