Golden West College Incident Reporting Form

Background Information

Your full name:

Your position/title:

Your phone number:

Your email address:

Email address must be of a valid format.

Your physical address:

Nature of this report(Required):

This field is required.

Urgency of this report(Required):

This field is required.

Date of incident(Required):

This field is required.

Time of incident:

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If not certain, please indicate approximate time

Location of incident(Required):

This field is required.

Specific location:

Involved Parties

Please enter as much information as possible so that the case manager can properly investigate the incident. If the person is not a student, please include a Driver's Licence Number (if possible).

Name

Role

ID Number

DOB (YYYY-MM-DD)

Phone number

Email address

Address (if known)

Questions

The following information is very important. Please clearly describe the facts in the situation and include all pertinent information.

Why are you reporting this incident?(Required) This field is required.

Please provide specific details, and include only the facts in the situation. If you have any supporting documentation, you may upload those to help the case manager evaluate the situation.(Required) This field is required.

Is the student aware that a referral is being submitted on their behalf? Answer yes, no, N/A(Required) This field is required.

What referrals/resources have you already provided to the student? Suggested Referral Sources: ACT/Mental Health: https://www.goldenwestcollege.edu/student-health-center/index.html Homeless: https://www.goldenwestcollege.edu/homeless-resources/index.html Basic Needs: https://www.goldenwestcollege.edu/student-equity/ally-center/index.html Sexual Misconduct/Title IX: https://www.goldenwestcollege.edu/titleix/reporting-options/index.html(Required) This field is required.

Who is your Dean/Supervisor?(Required) This field is required.

Supporting Documentation

Please attach supporting documentation. You may attach photos, videos, Word documents, or scanned PDF files to support your rationale for reporting this incidence. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

Copy your Dean/Supervisor

Email me a copy of this report

Background Information

Involved Parties

Questions

Supporting Documentation

Copy your Dean/Supervisor

Submission