KSU Office of Judiciary Programs
Residential Misconduct Incident Report
please print this form and return it to the Office of Judiciary Programs
CRL Name: _____________________________________________________ Date: _________________________
Residence Life Department _______________________________________ Phone: ________________________
Student Involved in the Misconduct:
Name:___________________________________________________ KSU
ID#: : __________________________
Community / Address:___________________________________________________________________________
_____________________________________________________________________________________________
Misconduct
Occurred:
Date of Incident:
____________________________________ Time of Incident: ___________________________
Location of Incident:_____________________________________________________________________________
Others Involved in Incident: _______________________________________________________________________
KSU Student Code of Conduct section(s) allegedly violated: IIIR (Residential Code of Conduct Violation)______________
___________________________________________________________________________________________________
__________________________________________________________________________________________________________________
Explanation of Incident: (Attach additional pages, if needed)
This statement is a true and accurate representation of the facts of the
incident.
CRL Signature _____________________________________________________ Date: ____________________________
__________ I do not admit responsibility for violating the Residential Code of Conduct Section(s)
and request a formal judicial hearing.
Student Signature:_________________________________________________________________Date:_______________
__________ I admit responsibility for violating the Residential Code of Conduct Section(s).
Student Signature:_________________________________________________________________Date:_______________
__________ I admit responsibility for violating the Residential Code of Conduct Section(s)
with a written explanation.
Student Signature:_________________________________________________________________Date:_______________
Explanation: (Attach Additional Pages if Necessary)
Remedy Agreed Upon (if any):____________________________________________________________________________
_______________________________________________________________________________
Deadline For Completion (if applicable):____________________________________________________________________
_______________________________________________________________________________
For Judiciary Program Office Use Only
Received:______________________________________________ File Number _____________________________
Follow up action (if any): __________________________________________________________________________
_______________________________________________________________________________________________