Student Code of Conduct – Incident Report Form

If you have any questions, please contact Zomar Peter via Email or call (252)638-4597. If reporting a medical emergency or injury, please complete the Student Accident Report.

If you are human, leave this field blank.

Incident Information

Date of Incident *

Time of Incident *

Location of Incident *

Student(s) involved

Please select the number of students involved in the incident One Two Three

First Student

First Name *

Last Name *

Student ID Number *

Email Address *

Phone Number *

Second Student

First Name *

Last Name *

Student ID Number *

Phone Number *

Third Student

First Name *

Last Name *

Student ID Number *

Email Address *

Phone Number *

Witness Information

Please select the number of students who witnessed the incident One Two Three

First Witness

First Name *

Last Name *

Student ID Number *

Email Address *

Phone Number *

Second Witness

First Name

Last Name

Student ID Number

Email Address

Phone Number

Third Witness

First Name

Last Name

Student ID Number

Email Address

Phone Number

Additional Notes

In the space below, describe the incident that occurred and indicate the specific violation. The Code (Standards of Conduct) can also be found in the Student Handbook.

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