* Type of Incident * Incident Day/Date Range * Incident Location(s) (Bldg/Dept) Person Involved * Name * Position * Department/Area Description of Incident *Providing the most detail possible about your concern will better assist us with conducting a thorough evaluation of this matter. Specific details are needed to identify potential violations and the extent to which they have occurred. Your assistance in providing this information is greatly appreciated. Potential witnesses (please indicate what additional information they may be able to provide) * Would you like to be contacted Yes No *Confidentiality Statement - LBCCD can never guarantee that the information provided by an individual will remain confidential. LBCCD cannot share the specifics of an administrative determination where it relates to confidential information. During an inquiry of this nature, the parties most directly connected to the matter will be notified of the process. This may include the immediate supervisor of the parties involved, the Human Resources Department, and any individuals who can provide any relevant information concerning the matter under evaluation. For Security: Enter the text that appears in the graphic above.The security feature is case sensitive. * Captcha *Required Fields