Incident/Concern Report Form

This form is used to document concerns related to an ESP student’s well-being, behaviour, accessibility barriers, or safety. It is also used to ensure appropriate follow-up, communication, and accountability. If a student is at risk of harming themselves or others, call Campus Safety at 613-520-4444. Please note that according to privacy legislation students have the right to request a copy of this report.

Your Name(Required)

First Chosen name(s) – optional Last Pronouns – optional

Please put the pronouns that you wish your coworkers to use when referring to you. Our standard practice is to include your pronouns with your profile on our website. This field can be updated at any time by emailing ESPFacilitators@carleton.ca.

Carleton Email Address(Required)

Your Role at ESP(Required)

Student Name(Required)

First Chosen name(s) – optional Last Pronouns – optional

Please write the name of the student who you are filing a report about. If multiple students were involved in one incident, please write their names in the box below.

Additional students involved in the incident (if applicable)

Please write the additional students’ first (chosen) & last names.

When did the incident/concern occur? Enter date(s) if applicable, or N/A.(Required)

Where did the incident/concern occur? (e.g., in a specific class or workshop, during a coaching appointment, via email, etc.)(Required)

Type of Concern (Select ALL that apply)(Required)

Academic Difficulties

Attendance

Behaviour/Disruption

Mental Health/Emotional Well-Being

Accessibility/Accommodation

Student Does Not Complete Work/Disengaged

Social Skills/Social Connections

Other

If you selected Other, please elaborate here.

Briefly describe the concern. Focus on the facts (what you saw/heard and when) rather than speculating.(Required)

Briefly describe any action you have taken. (e.g., spoke with student privately, suggested Advising appointment, etc.)(Required)

How urgent is follow-up?(Required)

Low (general support, can be monitored)

Medium (needs staff follow-up in 3 or more business days)

High (needs staff follow-up within 1-2 business days)

Have you reported this concern/incident to anyone? (Select ALL that apply.)(Required)

My Coordinator

My Team/Squad Leader

ESP Advisor

ESP Professor

I have not reported this to anyone

How is this concern affecting you? (Select ALL that apply.)(Required)

Harder for me to do my job

Worry/Stress

Extra Time/Workload

Other

If you selected Other, please elaborate here.

How is this concern affecting other students? (Select ALL that apply.)(Required)

Other students seem uncomfortable

Other students’ learning is affected

Other students avoid attending classes/workshops

Other students are aware of the concern, but don’t seem affected

Other students are not aware of the concern

Other

If you selected Other, please elaborate here.

Is there anything else the ESP staff should know?

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Centre for Initiatives in Education

613-520-2804

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