Communication Information Form

Communication Information Form

Office of Residence Life

Defiance College:

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(S) ALLEGEDLY INVOLVED

Name	Date of Birth	Building/Room #	Cell Phone	Alleged Involvement (see codes below)

INVOLVEMENT CODES

Abuse (AB)

Aggravated Assault (AGA)

Alcohol (AL)

Appliances (AP)

Arson (ARS)

Burglary (BUR)

Classroom Disruption (CD)

Disorderly Conduct (DC)

Drugs (DG)

Environmental Safety (ES)

Failure to Comply (FC)

Fire Safety (FS)

Firearms/Weapons (FW)

Guest/Visitor (GT)

Harassment (HA)

Intimidation (INT)

Larsony (LAR)

Liquor Law Violation (LIQ)

Medical (ME)

Mental Health (MH)

Murder/Non-Negligent Manslaughter (MNM)

Negligent Manslaughter (MNN)

Medical Transport (MT)

Motor Vehicle Theft (MVT)

Noise (NS)

Other (OTH)

Physical Assault (PA)

Person of Concern (PC)

Pets (PE)

Room Modification (RM)

Robbery (ROB)

Sexual Assault (SA)

Student of Concern (SC)

Solicitation (SO)

Safety/Security (SY)

Theft (TH)

Tobacco Products (TP)

Trespassing (TRP)

Vandalism (VN)

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.

Person Completing Report

Email Address

Incident Date