Information Report

Black Hills State University

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Supplemental

Blank Information Report
2011-2012 PDF

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Information Report

Person(s) Involved:

Please select the campus/location where the violation has occurred or the campus closest to the location of the incident.

Campus/Location:

Please enter the alleged violator's first name.

First Name:

Please enter the alleged violator's last name

Last Name:

Please enter the alleged violator's student ID or valid ID number.

ID#:

Please enter the alleged violator's address.

Address:

Please enter the alleged violator's telephone number

Phone:

Please enter the alleged violator's date of birth.

Date of Birth:

Please enter the alleged violator's first name.

First Name:

Please enter the alleged violator's last name.

Last Name:

Please enter the alleged violator's ID number.

ID#:

Please enter the alleged violator's address.

Address:

Please enter the alleged violator's phone number.

Phone:

Please enter the alleged violator's date of birth.

Date of Birth:

Reporting Person:

Please enter today's date.

Today's Date:

Select Date

Please enter a value for New Field

First Name:

Please enter your last name.

Last Name:

Please your address.

Address:

Please enter your BHSU Affiliation.

BHSU Affiliation:

Please type your electronic signature. Remember to include your middle initial.

Signature:

Please enter your BHSU email address.

Email Address:

Warning- It is a violation of the Student Code of Conduct to report false or misleading information.

Description of Complaint/Incident:

Please enter the incident date.

Incident Date:

Select Date

Please enter the incident time.

Incident Time:

AM
PM

Please enter the incident location.

Incident Location:

Please provide a description of the complaint and/or incident.

Description of Complaint / Incident:

Witnesses:

Please enter witness first and last name.

Name:

Please enter the witness address.

Address:

Please enter the witness phone number.

Phone:

Please enter the witness first and last name.

Name:

Please enter the witness address.

Address:

Please enter the witness phone.

Phone:

CONTACT INFORMATION:
Black Hills State University
Office of Admissions
1200 University St. Unit 9502
Spearfish, SD 57799-9502
605.642.6343
admissions@bhsu.edu

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