INCIDENT REPORT FORM

This information is delivered immediately to the Associate Dean for Student Affairs and to a neutral third party. The Associate Dean and third-party monitor will ensure that submissions are routed to the appropriate party for follow-up.

Title IX submissions are delivered to Dr. Tracy Hill and the Title IX team. For more information on Title IX, please visit our website.

This form must be submitted to initiate any disciplinary or grievance process.

For questions or concerns, please contact Casey Himmelsbach - cjhimmelsbach@noordacom.org or 385-378-5171.

Your Information

First Name*

Last Name*

Your Role *

Select or enter value

Your Phone Number

Phone

Your Email

Incident Information

Student Name*

List the student involved in the incident. Please submit a separate form for each student.

Cohort

Select or enter value

Date of Incident*

Please provide the date that the incident occurred. If multiple dates are associated with the incident, please provide the most recent date and list all others in the text box below.

Student Reported - Incident Type

Student recognition or kudos

Concern for student

Student conduct - includes professionalism events that may occur on campus, in community events, or in clinical settings

Title IX report - sexual harassment, violence, or discrimination

DEI report

Feedback about clinical rotation experience (microaggression, safety concerns, general feedback about preceptor)

Other - please specify in the description

Additional People

Please list any additional people you believe should be contacted regarding the referenced feedback. Please include their contact information is possible. This could be another employee, a student, or a community member/preceptor.

Please provide information about the incident. Helpful information includes time, location, information about the student behavior/action.

File Upload

Please attach any relevant information

Drag and drop files here or

Affirmation*

I verify the information contained within this report from is true and accurate to the best of my knowledge. I understand that the information provided, including my name, may be released to the Respondent as part of any student conduct process and that a conduct meeting may occur to address any allegation(s) that have been made. I further understand that the determination of whether or not the Student Code of Conduct has been violated resides with the College via the conduct processes.

I understand and agree with the Affirmation Statement.

Please check this box if you are a student who is requesting this incident be escalated to a grievance.

Send me a copy of my responses

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