Online Student Disciplinary Referral Form

Required Incident Information *
Date * Include Campus Police
Student Name * Student ID *
Referring Staff * Hall *
Immediate Supervisor * Phone Number *
Date(s) of Incident(s) *
Description of Incident(s) *

Alleged articles violated, see Student Code of Conduct for full text. (Check all that apply.)
	Disruptive Conduct		Alcohol, Drugs and Drug Paraphernalia
	Threats, Assaults and Fighting		Defamation
	Obscenity and Vulgarity		Initiation and Hazing
	Fraud, Misrepresentation, Extortion and Theft		Endangering the Health and Safety of Others
	Obstruction		False Imprisonment
	Harassment, Stalking, and Discrimination		Sexual Harassment
	Sexual Misconduct		Vandalism, Littering, and Destruction of Property
	Forgery		Emergency Alarms and Fire Control Devices
	Arson		Unauthorized Entry and Duplication of Keys
	Unauthorized Access and Tampering		Solicitation and Posting of Notices
	Violation of Federal, State or Local Law		Violation of College Policies, Rules or Directives
	Defiance of Authority and Untruthfulness		Possession of Weapons or Dangerous Items
	Pets and Animals		Conspiracy and Encouragement
	Attempted Violation		College Property in Room
	Cooking/Appliances		Gambling
	Overnight guest/Visitation		Noise
	Smoking

Additional Information
Is there any documentation or other physical evidence to support these allegations? (If yes, copies will be requested.) No Yes
Staff action taken prior to administrative referral.
Is there any documentation to support this previous action? (If yes, Copies will be requested.) No Yes
Any prior conference(s) with Head Resident or Coordinator? No Yes
If Yes, please list date(s)
Any prior conference(s) with student? No Yes
If Yes, please list date(s)
Any additional information you would like to include?
Is this submission for documentation only or are you requesting follow-up Action? Documentation Only Follow-up Action

Upon submittal, please call your Supervisor to verify your referral has been received.