Anne Arundel Community College

INCIDENT REPORT FORM

Individuals alleging an act of student misconduct by an Anne Arundel Community College student should complete this form and notify their immediate supervisor. The supervisor will submit the form  as soon as possible, but no later than 30 days after obtaining knowledge of the incident to the  Dean of Student Services.

PERSON SUBMITTING THIS REPORT:

Name:                                                                          Telephone No.

Address:

            (Street)                         (City)                           (State)              (Zip Code)

ALLEGED OFFENDER:

Name:                                                                          Telephone No.

Address:

            (Street)                         (City)                          (State)              (Zip Code)

DATE OF INCIDENT                                                                  TIME OF INCIDENT

DESCRIPTION OF ALLEGED INCIDENT:

INCIDENT REPORT FORM

Page 2

List names, addresses and phone numbers of all witnesses:

SIGNATURE OF INDIVIDUAL SUBMITTING THIS REPORT:

DATE SUBMITTED:  ___/___/___