Student Incident Report Form

Contact Us

SBIT@lagcc.cuny.edu

Student Incident Report Form

If you feel a student is a threat to themselves and/or the college community, you can refer the student to the Student Concern Assessment and Response Team by completing this form and clicking the “Submit Form” button at the bottom of the page.

Full Name

Department

Email(Required)

Phone(Required)

Incident Information: Student(s):

Student Info

Full Name

ID number if known

Incident Date

Incident Location

Incident Time

:

Incident Location Details

Did the incident happened in a classroom / library / lobby / cafeteria / other?

Any witness? (students, employee, others)

Tell Us More:

Behavior

Speech

Other Behavior, Explain:

Other Speech, Explain:

Mood

Thought

Other Mood, Explain:

Other Thought, Explain:

Appearance

Judgement

Other Appereance, Explain:

Other Judgement, Explain:

Classroom

Participation

Personal

Do you believe this student is at risk for harming him/herself?

Do you believe this student is at risk for harming others?

Have you reported these concerns to anyone on campus?

If “Yes”, to whom did you report these concerns and when?

Have you spoken to the student about these concerns?

If “Yes”, please describe how the conversation went. Incident details / additional comments:

Name

This field is for validation purposes and should be left unchanged.