General Incident Report Form
Andrew College is concerned about the safety and well-being of all students, faculty, and staff. In an effort to keep the lines of communication open across campus, we are using this incident report form. This form provides an avenue for all faculty, staff, and students to report disturbing behavior, suspicious activity, or other violations of the College's policies to the Office of Student Affairs. Incidents may include (but are not limited to):
  • Violations of the Student Code of Conduct
  • Suicidal Ideations/Drastic and/or sudden change in behavior/hygiene
  • Student/Faculty/Staff Injury - (falls under General Information)
If you have questions about this process prior to filling out an incident report, please contact the Office of Student Affairs at 229-732-5950/5952.

If you are considering filing a student concern related to sexual assault, sexual harassment, relationship violence, or stalking, we encourage you to contact Chicquan Cannon, Title IX Coordinator and Compliance Officer, at 229-732-5950 or chicquancannon@andrewcollege.edu.

In the narrative, please outline as much information about the concern/incident as possible, including what happened, when and where the incident occurred, and the student(s) involved.  (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.

 Confidentiality of educational records is outlined by the Federal Education Rights and Privacy Act (FERPA).
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BACKGROUND INFORMATION
Your Full Name:  
Your phone number:
Your e-mail address:
Your hall/room number or physical address:
You are a________:
Clear selection
Nature 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. For non-students, please list a SSN or Drivers License number in place of Student ID number.
Name/Student ID # / Hall / Room #  *
Please include the any names, hall and room number of parties involved. Ex. Nayvadius Cash/1120983/Rhodes Hall - 217
Phone Number:
Please include the phone number of any involved parties if known.
Witnesses
Please include the any names, hall and room number of any witnesses.
DESCRIPTION / NARRATIVE
Please provide a detailed/ specific description of the incident/concern using concise, objective language.  In the narrative, please outline as much information about the concern/incident as possible, including what happened, when and where the incident occurred, and the student(s) involved.  (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.)
 *
Did you contact one of the individuals below? You can check more than one. *
Required
SUPPORTING DOCUMENTS
Please e-mail any photos, video, email, and/or other supporting documents to osa@andrewcollege.edu
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