KCC Dean of Students Incident Report Form

Office of the Dean of
Student Affairs

718-368-5563 (Phone)
718-368-4609 (Fax)

Office of the Dean of Student Affairs


Assessment and Care Team Incident Report
Student First Name:
Student Middle Name
Student Last Name
Last 4 digits of SSN ID (if available):
Student Email Address (if available):

Your Name:
Your Title:
Your Phone:
Your Email Address:

Date of Incident:
Time of Incident:
Location of Incident:
Please provide a detailed description of the incident or nature of your concern: