Student Behavioral Conduct Incident Reporting Form

This form is to be used to report student-behavior incidents of concern to the Excelsior University Student Rights and Responsibilities Office. All submissions are considered private. Details will be shared only with parties directly involved in the investigation.

Important: This is an official document that may be reviewed by the Respondent with Complainant contact information redacted. Anonymous complaints may inhibit our ability to respond and/or investigate.

Please do not use this form if your complaint is related to any of the following:

For student complaints related to academic dishonesty, grades you have received, etc., please refer to the University Student Appeals Policy.
For student complaints related to sexual violence, sexual harassment, and/or Title IX, please contact the Excelsior UniversityTitle IX Office: 844-427-4356; acs@excelsior.edu
For complaints related to the behavior of Excelsior University employees, including instructional faculty, please contact the Excelsior University Office of Human Resources: 518-464-8532; HRConcerns@excelsior.edu

There are formal thresholds under which an Incident Report may lead to a formal investigation. Those thresholds and other information regarding the Excelsior University Policy on Student Behavioral Conduct can be found by clicking this link.

*All fields designated by an asterisk are required.

Complainant Information

What is your affiliation with Excelsior University?

Your Name (if anonymous, please type ANONYMOUS)

Your Student ID Number (if known)

Your Excelsior University Department

Enter your Excelsior University Department

Please state your affiliation

Your Contact Information:

Phone Number (enter numbers only)

E-mail Address

Details of Incident

Please complete the following information related to the incident.

Respondent Name (name of student you are alleging in this complaint)

Are there additional Respondents?

Please add per line each additional Respondent:

Incident Date/Time (ex: 01/11/2022 10:00 AM) Estimate of date and time is okay

Are there additional incident dates and times?

If there are additional Incident Dates and Times, please add each per line (ex: 12/27/2021 10:00 AM):

Did this incident occur in an Excelsior University course?

Please provide as much of the following course information as you know:

Course Abbreviation (BIO, ENG, etc.):

Course Number (101, 102, etc.):

Course Name:

Please specify where the incident happened (e.g. social media platform, personal e-mail, business name with address)

Please Provide a brief description of the incident

Tips: In recalling the incident to the best of your ability, please do not censor explicit language or sanitize obscene behaviors. Do not diagnose the Respondent or any individuals related to the complaint. Stick to factual, not editorial information; for example, report that, “The Respondent is repeatedly contacting me outside of class despite my repeated requests to stop vs. the Respondent “is a paranoid stalker, who won’t stop e-mailing me.” Please also specify whether there were witnesses to the incident.

Terms: The information I am submitting as part of this complaint is factual and complete to the best of my knowledge. I understand that submission of this form does not require Excelsior University to conduct a formal investigation into my allegations; that knowingly providing false statements is a violation of the Excelsior University Code of Conduct and is a violation of Excelsior University employee policies, both subject to disciplinary action; and that retaliation as a result of filing or participating in the investigation of a complaint is strictly prohibited. Retaliatory conduct could result in dismissal from the University for students and discipline up to and including termination of employment for employees.

I agree.