Pellissippi State Community College
Dean of Students Office
Template for Documenting Disruptive or Concerning Behavior
The following template will guide you through the incident documentation process to include necessary information in the event of a BIT or student conduct referral. You may complete this form or use it as a guide when using your own method of documentation. Include the specific facts of what you saw, heard and said. Refrain from stating personal judgments or opinions. Keep this document and other information as needed for your records. ______
Date of Incident: Click here to enter a date.
Involved Students:
Student #1 Click here to enter text. P# Click here to enter text. Phone # Click here to enter text.
Student #2 Click here to enter text. P# Click here to enter text. Phone # Click here to enter text.
Witnesses:
Witness #1 Click here to enter text. P# Click here to enter text. Phone # Click here to enter text.
Witness #2 Click here to enter text. P# Click here to enter text. Phone # Click here to enter text.
______
Incident Description:
Provide a description of the incident or behavior of concern. Please provide details in chronological order and include your observations of specific behavior, and specific statements, even if they are considered to be vulgar or are uncomfortable for you to repeat.
Describe what happened here.
Is this the first time you’ve addressed this concern with the student?
☐ Yes
☐ No – If no, when did you first discuss this concern with the student? Date
What was the agreed upon resolution?
Describe the resolution here.
(Continued)
What action has been taken during or after the incident?
2
☐ I had a conversation with the student about the disruptive or concerning behavior.
☐ The student was asked to leave the classroom and speak with me in private before the next class meeting.
☐ Student was referred to the BIT
☐ Campus Police were contacted to respond.
☐ I’ve discussed this concern with my supervisor, academic dean, or campus dean
☐ I’ve discussed this concern with the dean of students.
☐ I’ve referred the student to campus resources. Which one(s)? Name of resource
2