Incident or Concern Report Form

We are committed to your safety, well-being, and fostering a positive and supportive collegiate experience. Please complete this form with as much detail as possible.

If this is an emergency or, if you are in immediate danger please contact the campus police immediately at (706) 821-8235.

I want to remain anonymous

I want to remain anonymous Yes No
Important: We respect your right to maintain your anonymity. However, maintaining anonymity may limit investigators' ability to gather additional information, clarify details, or follow up on evidence, which can delay and or limit the overall findings of the investigation.
Today's Date Today's Date / MM / DD YYYY
1. Person Reporting
Name Name First Middle Last
Paine College Email
Phone Phone - ### - ### ####
Your Current Residence
Off-Campus Address (commuter only) Off-Campus Address (commuter only)
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
2. Incident or Concern Information
Date of Incident or Concern Date of Incident or Concern / MM / DD YYYY
Location of Incident
Person(s) Involved
Type of Incident or Concern

Type of Incident or Concern Academic Faculty/Staff Financial Aid Housing Discrimination/Harassment Accessibility Student Services Safety Discrimination Harassment Physical Altercation Sexual Harassment / Sexual Misconduct Accessibility/Disability Services Student Conduct Student Well-Being / Mental Health Concern Other Other
3. Description of Incident or Concern
Please describe what happened, including relevant dates, times, and individuals involved.
4. Previous Attempts to Resolve
Have you previously reported or discussed this issue?

Have you previously reported or discussed this issue? Yes No
If yes, with whom and what was the response?
5. Requested Resolution
What outcome or resolution are you requesting?
6. Supporting Information
Do you have supporting documents or witnesses?

Do you have supporting documents or witnesses? Yes No
If yes, please describe or list them:
If yes, please upload what you can
7. Additional Concerns
Are there any immediate concerns, safety issues, confidentiality concerns, or accommodations needed?
8. Certification
I certify that the information provided is true and accurate to the best of my knowledge.
Your Signature

Draw or Type

Draw your signature into the box below. I understand this is a legal representation of my signature. Clear

Full Name

Draw your signature into the box below. I understand this is a legal representation of my signature.

Incident or Concern Report Form

Incident or Concern Report Form

1. Person Reporting

2. Incident or Concern Information

3. Description of Incident or Concern

4. Previous Attempts to Resolve

5. Requested Resolution

6. Supporting Information

7. Additional Concerns

8. Certification