ࡱ> HJG5@ rbjbj22 +*XXTT84H$T xx:ddd$RPfd>"`ddpppd@8pdp p|Cl °{@_,0 ,dC2FCpdddTT XH(TTXý Community College Referral Form for Disruptive Behavior Please complete this electronic form as fully as possible. The information you share may be made available to the student and should reflect only what you have observed or of which you have first hand knowledge. In order to ensure that the Colleges standards for appropriate behavior are enforced consistently, it is important that you report all incidents of disruptive behavior to the Office of Student Development no matter how small or minor they may appear. Students Name: Student ID#: Dates(s) of Incident(s): Date of Report: Reported by: Department: Contact Phone: Check all that apply: ( Obstruction or disruption of teaching, research, administration, disciplinary procedures, or other College or District activities, including its public services function, or of other authorized activities; ( Physical or verbal abuse of any person or conduct which threatens or endangers the health or safety or any person; ( Causing or attempting to cause damage to College or District property or to private property on campus; ( Stealing or attempting to steal College or District property or private property on Campus, or knowingly receiving stolen College or District property or private property on campus; ( Disruptive behavior, willful disobedience, habitual profanity or vulgar, or the open and persistent defiance or authority, or persistent abuse of College or District personnel; ( Hazing or any act that injures, degrades, or disgraces or tends to injure, degrade or disgrace any fellow student or persons; ( Disorderly conduct or lewd, indecent or obscene behavior, conduct or expression on District-owned or controlled property, or at District sponsored or supervised function; ( Willful or persistent smoking in any area where smoking has been prohibited by law or by regulation of the College or District; ( Committing or attempting to commit robbery or extortion ( Willful misconduct that results in injury or death to a student or to College or District personnel or which results in cutting, defacing, or other injury to any real or personal property owned by the College or District or on the campus; ( Unauthorized entry or use of College or District facilities; ( Violation of College or District policies or of campus regulations including those concerning registration of student organizations, use of College or District facilities, or the time, place, and manner of public expression; ( Unlawful possession, use, sale, offer to sell, or furnishing or being under the influence of any controlled substance as listed in California Health and Safety Code Section 11053 et seq., an alcoholic beverage, or an intoxicant of any kind; or unlawful possession of, or offering, arranging or negotiating the sale of any drug paraphernalia, as defined in California Health and Safety Code Section 11014.5; ( Use, possession, or sale of any firearm, knife, explosive, or other object that could be classified as a weapon as a weapon (unless the student has specific authorization from a College or District); ( Gambling on College or District property; ( Engaging in expression which is obscene, libelous or slanderous, or which so incites students as to create a clear and present danger of the commission of unlawful acts on College or District premises, or the violation of lawful College or District regulations, or the substantial disruption of the orderly operation of the College or District. ( Persistent, serious misconduct where other means of correction have failed to bring about proper conduct. ( Other violations of Student Code of Conduct____________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Please provide a brief summary of the incident(s) (with dates and times) as they occurred here:  For Office Use only: ( No Action Needed. For documentation only. ( INFORMAL CONSULTATION REFERRAL The reporter may request a consultation with Dean of Student Development or Designee. The student may or may not be notified of the report but may not necessarily be required to meet with a school official. Informal referrals are for relatively minor violations or concerns and may be retained to determine if a pattern of behavior is observed that may lead to formal action. An informal referral will not necessarily result in any specific action. ( FORMAL DISCIPLINARY or CONCERN REFERRAL Please submit electronically or in hard copy to: John Cognetta OR Michele LeBleu-Burns College Disciplinary Officer Dean Student Development & EOPS Student Development & EOPS Hinson Campus Center Office #165 Hinson Campus Center Office #165 ACTION TAKEN:  DATE \@ "M/d/yy" 3/1/11 TIME \@ "h:mm AM/PM" 5:46 PM  PAGE 1 AB^}      c d   UVW|}~IJKvwxBCDE׽ӴӪתתתӪӪӪתתӪӪӪӪӪӪӪӴ johvhphHhpCJhvhp5 h+ahp hZ,hphp hvhp hHhphvhpCJ hp5CJ hvhp5CJ CAB  7 8 f g ~  b c   TU$$$$$$$$$$$$$v:$$$$$$$$$$$$$$$gdp$a$gdpnq{|HIuvBC34$$$$$$$$gdp   !34:<RSZ[\]cdefqrݹݯvhp0JmHnHu hp0Jjhp0JUhpmHnHujhpUhphvhpCJhvhp5CJhvhpCJhvhp5hvhpCJ johvhphvhpCJ hvhp#jhpUaJmHnHsHtH$ 67b $dNgdpgdpb   hijklmnopqr$$ $dNgdp)0P:pp/ =!"#$`%@@@ NormalCJ_HaJmH sH tH DA@D Default Paragraph FontRiR  Table Normal4 l4a (k(No List 4@4 fHeader  !4 @4 fFooter  !.)@. 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L^`LhH.2$6V l        p ms@}}t }}r`@UnknownGz Times New Roman5Symbol3& z Arial;Wingdings 1hզn F(F $A "A "$4dJ#Q? cDe Anza Community CollegeFHDA  Oh+'0L1  0 < H T`hpxý Community College.e AFHDAza HDANormal  rm12mMicrosoft Word 10.0@u@0_j@*@ؔ{AG/VT$mr   ."System]r0h$ -@Times New Roman-  2 X D-'2 X3/1/1122222 X5:46 PMt2228X 2  D 2 G 1D2 2 y  D 2 h D-'{@Times New Roman- 2 DD`/2 e Anza Community College;!`K:C"`DonKJ%,C!`C%%;C; 2 1  DI@Times New Roman-D2 m&Referral Form for Disruptive Behavior N4'4''3!A:'Y';'T!.';: !:4N4:4: ;' 2   D5- 2 X D-52 XPlease complete this electro8,,',,2N2,,2',,-!2:2 nic form as fully as possible. 2,!2!N,'!20,'23''2,=2 H !The information you share may be v=2,2!2!N,22122'2,!,N.03,2 X]made available to the student and should reflect only what you have observed or of which you N,2,,2,,2,22,'32,2,22'2222!,!-,320H2,0223,2,22'-"2,22!2!H2,202222 qXhave first hand knowledge.2,2,!!'2,22223H,32, 2 q Dk2 q@In order to ensure that the Colleges standards for appropriate 22!2-!2,2'2",2,2,C2,1-!'',22,!2'"2!,22!22!,,82 Xbehavior are enforced consiste2,2,22!-!,,3!2!-,2,32'',n2 Bntly, it is important that you report all incidents of disruptive 2/'N22!,22,022",22!,2,2-2'2!2'!222,2 WX[behavior to the Office of Student Development no matter how small or minor they may appear.u2,2,22!22,H"!,,3!822,2H,2,22N,222N,,!22H'N,2!N22!2-0O.0,22-,! 2 W9 D 2 WR D. 2 X D-@Times New Roman-"2 ?XStudents Name:8!88,8!!'H2S," 2 ?" D 2 ? D, 2 ? D, 2 ?4 D, 2 ?`  D, 2 ?  D, 2 ?  D,2 ? Student ID#:8!88,8!'H2! 2 ?  D6 2 X D6/2 %XDates(s) of Incident(s):H2!,'!'!2"'8,8,8!!'!" 2 %$ D 2 % D, 2 %4 D, 2 %`  D, 2 %  D, 2 %  D,"2 % Date of Report:H2!,2"H,82,!! 2 %} D7 2 X D62 X Reported by:H,82,!,882" 2  D$ 2  D, 2  D, 2  D,2 4 Department:H,82,"S,8!" 2 Z  D2 2   D, 2   D, 2  Contact Phone:H28!2,!<828,! 2 { D7 2 ~X D6-+2 XCheck all that apply:sC2,,2,2,,22/ 2  D.@Times New Roman- 2 S X D%@Wingdings- 2 XoDY- 2  D-2 NObstruction or disruption of teaching, research, administration, disciplinary H2'!2,222!2'!22222!,,,231",',-!,2,3N2'!,222',22,"0 2 5 X D,2 5 Sprocedures, or other College or District activities, including its public services s2!2,,22",'2!22-!C2,2,2!H'!,-,2,'2,2221'222,',!2,,' 2 X D,@2 #function, or of other authorized aco!22,222!2!22,!,232!-,2,,2  tivities;2,' 2   D- 2  X D-- 2 XoDY- 2  D2 SPhysical or verbal abuse of any person or conduct which threatens or endangers the s830',,2!3,!2,,22(,2!,402,!'223!,2222,H2,22!,,,2'3!,22,31-!'2, 2  X D,2  health t2,,2 2   D/2  or safety or any person;2!',!,02!,402-!'22 2  ` D- 2 t X D-- 2 XoDY- 2  D2 TCausing or attempting to cause damage to College or District property or to private C,2'212!,,N2212,,2',2,O-1,2C2-1,2!H'!,2!22,!02!22!2,, 2 Z X D,(2 Z property on campus;r2!22,!022-,N22' 2 Z  D- 2 X D-- 2 @XoDY- 2 @ D"2 @Stealing or att8,,212!,s2 @Eempting to steal College or District property or private property on ,N2312',,C2,1,3!H'!,2!22,!02!2!3,,2!22-!022 2 X D,2 WCampus, or knowingly receiving stolen College or District property or private property C,N22'2!222H210"-,,221'2,2C2-1,3"H'!,2!22,!02!2!3,,2!22-!0 2 &X D,2 & on campus;22,,N22' 2 &N D- 2 X D-- 2 XoDY- 2  D2 TDisruptive behavior, willful disobedience, habitual profanity or vulgar, or the openH'!222,2,2,22!H!22'22,2,2,,3,22-2!2!,203!222,!2!2,22,22 u and h,22 2 X D,2 Wpersistent defiance or authority, or persistent abuse of College or District personnel;2,!'',22,!,3,,2!,222!02!3,!'',2,22(,2!C2,2,2!H'!,3,!'222, 2  D. 2 X D-- 2 eXoDY- 2 e D2 eVHazing or any act that injures, degrades, or disgraces or tends to injure, degrade or H,-212!,40,,2,22!,'2-1",2,'2!2(1",-,'2!,22'222!,2-1",2,2! 2 X D,F2 'disgrace any fellow student or persons;2'1!-,,,40!,2H'22-22!2,!'22' 2   D- 2 KX D-- 2 XoDY- 2  D72 Disorderly conduct or lewd, ieH'2!2,!0,2223,2!-H2\2 6ndecent or obscene behavior, conduct or expression on 22,,,22!22(,,2,2,2,22!,2223,2!,32!,''2222 2 1X D,2 1DistrictH'!, 2 1-D!2 1Nowned or controlled property, or at District sponsored or supervised function;2H2,22!,22!2,22!22,!02!,H'!-'222'2!,22!'22,!2',3!22,22 2 1 D- 2 X D-- 2 XoDY- 2  D2 VWillful or persistent smoking in any area where smoking has been prohibited by law or _!22!2,!'',2'N12212,40-!,,H2,",(N22212,'2-,22!222,230,H2! 2 X D,.2 by regulation of the Co;30"-12,222!2,C2&2 #llege or District;,2,2!H'!, 2   D. 2 X D-- 2 pXoDY- 2 p D^2 p7Committing or attempting to commit robbery or extortionC2NN212!,,N2212,2NN!222,#03!-32!22 2 p  D, 2 X D-- 2 VXoDY- 2 V D2 VZWillful misconduct that results in injury or death to a student or to College or District _!2M',2222,2,!,'2'222"/3!2-,22,'22,22!2C2,1,2!H'!, 2 X D,2 Tpersonnel or which results in cutting, defacing, or other injury to any real or pers2,!'222,2!H2,2!,'2'2,2212,",,312!22,!22"02,40!-,2!2,!'2 onal i22, 2 <X D,d2 <;property owned by the College or District or on the campus;2!22,!02H2,2403,C2,1,3!H'!,2!223,,,N22' 2 <  D. 2 X D--                    ՜.+,0  hp  ý College" A ý Community College Title  !"#$%'()*+,-./0123456789:;<=>@ABCDEFIRoot Entry F`b{K1TableWordDocument+*SummaryInformation(&|1DocumentSummaryInformation8?CompObjj  FMicrosoft Word Document MSWordDocWord.Document.89q