Behavior Incident Report

Behavior Incident Report

To report an incident, please provide the following information. Fields are not required in order to protect those who wish to remain anonymous. If a field is irrelevant to the incident, leave that field blank.
This form should be used to report violations related to non-academic misconduct, Title IX, student organizations and any concerns for the safety of a SouthArk student. Reasons to make a report could include, but are not limited to, the following:
- Self-injurious behavior
- Suicide attempt or talking about suicide
- Threats of harm to others
- Illegal drug use or abuse of prescription drugs
- Emotional distress
- Erratic behavior
- Unusual behavior
- Grieving student
- Victimization
- Discriminatory behavior
- General non-academic complaints
- Any violation of the student code of conduct, student organization policies or procedures, or sexual harassment/discrimination policy
Forms should be submitted electronically. Any SouthArk employee who becomes aware of an allegation must report the allegation as soon as possible. Students should also submit reports utilizing this form.

Members of the South Arkansas Community College (SouthArk) community, guests, and visitors have the right to be free from all forms of gender and sex-based discrimination and the right to participate in a safe environment conducive to learning.

Completion of this form does not constitute an open investigation. Once this form is completed and submitted, an initial assessment will be conducted to determine if the report rises to the level that warrants further investigation.

Throughout this process, SouthArk will protect the confidentiality and privacy of the reporting party to the extent possible and make every reasonable effort to abide by a reporting party's or victim's wish to remain anonymous. However, SouthArk must balance requests for anonymity/confidentiality with the safety of other members of the SouthArk community.

Filing a complaint does not preclude filing the same with an external agency nor does it extend any time limits one has for such filings.

This form is not an emergency incident report. If this is an emergency, call campus police at 870-866-9208 for West Campus, 870-310-5788 for East Campus, or 999 from an office phone. You may also use red or blue emergency phones or dial 911.
Report date and time

Month Day Year Hour Minutes AM/PM Option
Date and time when incident occurred

Month Day Year Hour Minutes AM/PM Option
Incident Type

Sex/gender based discrimination Non-Academic misconduct Danger to self or others Sexual Misconduct Student Organization Violation Discrimination (Non sex/gender based) Other
Reporter's Name

Mr/Ms/Mrs First Name Middle Name Last Name
Reporter's email
example@southark.edu
Reporter's Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Reporter's Role on Campus

Student Employee Visitor
Student ID (if applicable)
Reporter's Phone

Area Code Phone Number
Victim's Name

First Name Last Name
Victim's Preferred Name
Are you the victim? *
If you are the victim or complainant, you will be contacted related to supportive measures and next steps.
Below, tell us how you became aware of this incident.
Victim's Email
example@southark.edu
Victim's Phone

Area Code Phone Number
Victim's Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Victim's Role on Campus

Student Employee Visitor Unknown
Name of Assailant or Respondent if known

First Name Last Name
Assailant or Respondent's Role on Campus

Student Employee Visitor Unknown
List any contact information you have for the assailant or respondent
Incident Location (Please provide specific details):
Incident details
Do you know what motivated the incident?
Was a weapon involved?

Yes No
Do you have any reason to believe this incident represents a present threat of harm or danger to the victim or other member(s) of the college community?

Yes No
Please explain the reasons in support of your answer to the preceding question.
Was a report of the incident issued to the police or any other party? If so, list name and contact information.
List names and contact information for any witnesses to the incident.
Has anyone been arrested so far in relation to the incident?
Please upload any supporting documentation.

Browse Files

Cancel of
Further Comments
Notice of Non-Discrimination: South Arkansas Community College does not discriminate on the basis of race, color, gender, national origin or ethnic group, age, religion, disability, marital status, veteran status, sexual orientation or gender identity in educational programs or activities.
Statement of Non-Retaliation

The college will not tolerate retaliation of any kind against an individual who in good faith reports an incident. Retaliation is adverse treatment that occurs because of a report or investigation. Retaliation is grounds for disciplinary action.

Statement of Understanding

I understand that I am filing this complaint with South Arkansas Community College only. I also understand that by filing this complaint, I am not prevented or prohibited from filing the same complaint with an external agency including law enforcement. I understand that this complaint may warrant an internal investigation in accordance with the standards and procedures in the Student Code of Conduct and Title IX: Addressing Interpersonal Violence.

I further understand that intentionally making a false report is grounds for disciplinary action.
*

I certify that the above information is true and correct to the best of my knowledge. I understand submitting this form represents a formal complaint.
Behavior Incident Report

Created 05/31/2018

Revised 06/29/2021
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