Form to report an Incident/Accident/Complaint

Incident/Accident/Complaint Form

The following form is intended for anyone to report a complaint, concern, or incident. The appropriate department and/or staff member will follow-up with you regarding your report. Please note, information will be kept confidential as much as possible depending on the nature of the report.

Type of Report Being Submitted

Report Types

Academic Complaint or Concern: Complaint and/or concern about an academic program, course, grade appeal, or instructor.
Accident: Report of bodily harm as the result of an accident or incident on Southwest Tech property.
Employee Complaints: Complaint about a Southwest Tech employee.
Employee Concerns: Concern for the health and/or safety of a Southwest Tech employee.
Facility and Operational Complaints or Concerns: Complaint and/or concern about a facility or college operation/service.
(Examples: icy sidewalk or unreturned phone call)
Student Academic Misconduct: Allegation of a student violating the Academic Integrity expectations of Student Code of Conduct, Student Handbook, or program handbook.
(Examples: cheating, plagiarizing, asking another student for test questions and/or answers)
Student Behavioral Misconduct: Complaint and/or concern about a student violating the Student Code of Conduct or Student Handbook.
(Examples: bullying/cyberbullying, disruptive behavior, or fighting)

Choose the type of report being submitted

All fields are required unless stated.

Reporting Party Information

The information below pertains to the person reporting the issue.

Your First Name:
(optional)

Your Last Name:
(optional)

Your Phone Number:
(optional)

Your Email Address:
(optional)

Information for person of concern

This complaint or concern is regarding:

You Must Choose what the complaint or concern is regarding.

The information below pertains to the person of concern.

I am self-reporting.

Their First Name:

Their Last Name:

Program:
(if known)

Course:
(if known)

Their Phone Number:
(if known)

Their Email Address:
(if known)

Policy Name:

Description of Academic Complaint or Concern (4000 character limit)

Please add a description of your complaint or concern.

Incident Information

Date of Incident:

Time of Incident:
(if known)

Description of incident (4000 character limit)

Signature

Signature of reporting party:
(optional)