Communication Information Form

Office of Residence Life


The Communication Information Form is for reporting incidents and issues that occur on campus or that affect members of the campus community. If you or anyone you know has been involved in an incident that you feel the college should be made aware of, please fill out this form to the best of your ability. If you have any questions or concerns, please contact the Office of Residence Life at (419) 783-2563.

If you need immediate assistance, please call our Crisis Response phone at (419) 439-0359.


REPORTER INFORMATION
Person Completing Report
Email Address
Incident Date   Time:
Location:
PERSON(S) ALLEGEDLY INVOLVED
Name Date of Birth Building/Room # Cell Phone Alleged Involvement
(see codes below)
INVOLVEMENT CODES
Abuse (AB)
Alcohol (AL)
Appliances (AP)
Disorderly Conduct (DC)
Drugs (DG)
Environmental Safety (ES)
Failure to Comply (FC)
Fire Safety (FS)
Firearms/Weapons (FW)
Guests/Visitor (GT)
Harassment (HA)
Noise (NS)
Pets (PE)
Physical Assault (PA)

 

Room Modification (RM)
Safety/Security (SY)
Sexual Assault (SA)
Solicitation (SO)
Theft (TH)
Tobacco Products (TP)
Vandalism (VN) Additional Codes:
Alcohol Transport (AT)
Medical (ME)
Medical Transport (MT)
Mental Health (MH)
Mental Health Transport (HT)
Victim (VT)
Witness (WT)
Other (OT) please specify
DESCRIPTION OF THE INCIDENT
This section should be completed by the person who files the complaint or those who witnessed the incident. Describe the incident with as much detail as possible. Include only the facts of the incident as observed or reported - not your opinion. Describe your role and actions in third person. You may attach additional pages, if necessary.
 
STATEMENT

By submitting this report to Defiance College I certify that the information given on this application is complete and accurate to the best of my knowledge.

 
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