Student Conduct Reporting Form

Name: Antioch College Holiday Flea Market
Start: 2022-12-03T11:00:00-05:00
End: 2022-12-03T16:00:00-05:00
Location: South Gym (Wellness Center)

Please include as much information as possible regarding the incident and those involved. Your contact information in required so we can follow up regarding this incident. For more information, questions, comments, or concerns please contact StudentConduct@antiochcollege.edu. ***If this is an emergency, please call 911***
Your Information
Name*
First Last
Pronouns
Title/Position*
Email*
Phone*
Do you want this report to be made confidentially? The student conduct team must have your contact information for follow up, and will keep your identity confidential when possible.*
- Yes
- No
Date, Time & Location
Date of incident
MM slash DD slash YYYY
Time

: Hours

Minutes

AM/PM
Location/Building
Who Is Involved
Name
First Last
Pronouns
Role
Email
Phone
Add another person?
- Yes
- No
Name
First Last
Pronouns
Role
Email
Phone
Questions
Regarding this incident, are you concerned about your safety or the safety of others?
Did Public Safety or law enforcement respond to this incident? If yes, which agency (Antioch Public Safety, Yellow Springs Police, etc.)?
Did emergency personnel respond to this incident? If yes, was someone transported to the hospital?
Narrative & Resolution
Please provide as much detail as possible regarding this incident/concern using specific concise, objective language (who, what, where, when, why, and how). The use of direct quotes is encouraged, including profanity or abusive language that may have been used during the incident.
What action and/or resolution are you hoping for?
Please provide any files/evidence/photos/emails
Drop files here or

Accepted file types: jpg, gif, png, pdf, doc, docx, txt, Max. file size: 200 MB.