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.


Person Completing Report
Email Address
Incident Date   Time:
Name Date of Birth Building/Room # Cell Phone Alleged Involvement
(see codes below)

Aggravated Assault (AGA)
Alcohol (AL)
Appliances (AP)
Arrest (ARR)
Arson (ARS)
Burglary (BUR)
Damage and Destruction (DD)
Disruptive Behavior (DB)
Drugs (DG)
Environmental Safety (ES)
Failure to Comply (FC)
Fire Safety (FS)
Guest/Visitor (GT)
Harassment (HA)
Medical (ME)
Medical Transport (MT)
Mental Health (MH)


Motor Vehicle Theft (MVT)
Noise (NS)
Other (OTH)
Person of Concern (PC)
Pets (PE)
Physical Assault (HRM)
Room Modification (RM)
Safety/Security (SY)
Sexual Assault (SA)
Solicitation (SO)
Student of Concern (SC)
Theft (TH)
Threat/Intimidation (TB)
Tobacco Products (TP)
Unauthorized Entry (UE)
Weapons (WP)
Wheeled Devices (WD)

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.

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.