Behavior Intervention Care Team

Disciplinary Form

Note: Fields marked with an * (asterisk) are required.

Please complete this electronic form as fully as possible. Click into grey fields. Fields will grow as needed. The information you share may be made available to the student and should reflect only what you have observed or your specific knowledge of the incident.

Faculty/Staff InformationName *
Email *
Extension *
Department/Position *
Date of Report *

Student InformationStudent Name *
Student ID
Dates of Incident(s) *

Violations *

Possible violations of the "Student Code of Conduct" as documented in the College Catalog. Check any that apply:

(1) Causing, attempting to cause, or threatening to cause physical injury to another person or to one's self
(2) Possession, sale or otherwise furnishing a weapon, including but not limited to, any actual or facsimile of a firearm, knife, explosive or other dangerous object, or any item used to threaten bodily harm without written permission from a district employee, with concurrence of the College President.
(3) Use, possession (except as expressly permitted by law), distribution, or offer to sell alcoholic beverages, narcotics, hallucinogenic drugs, marijuana, other controlled substances or dangerous drugs while on campus or while participating in any college-sponsored event.
(4) Presence on campus while under the influence of alcoholic beverages, narcotics, hallucinogenic drugs, marijuana, other controlled substances or dangerous drugs except as expressly permitted by law.
(5) Committing or attempting to commit robbery or extortion.
(6) Causing or attempting to cause damage to district property or to private property on campus.
(7) Stealing or attempting to steal district property or private property on campus, or knowingly receiving stolen district property or private property on campus.
(8) Willful or persistent smoking in any area where smoking has been prohibited by law or by regulation of the college or the District.
(9) Engaging in harassing or discriminatory behavior. The district's response to instances of sexual harassment will follow the processes identified in Board Policy and Administrative Procedures 3430.
(10) Obstruction or disruption of classes, administrative or disciplinary procedures, or authorized college activities.
(11) Disruptive behavior, willful disobedience, profanity, vulgarity or other offensive conduct, or the open and persistent defiance of the authority of, or persistent abuse of, district/ college personnel in performance of their duties.
(12) Academic dishonesty, cheating, or plagiarism.
(13) Forgery; alteration or misuse of district/college documents, records or identification; or knowingly furnishing false information to the district/college or any related off-site agency or organization.
(14) Unauthorized entry to or use of district/college facilities.
(15) Violation of district/college rules and regulations including those concerning student organizations, the use of district/ college facilities, or the time, place, and manner of public expression or distribution of materials.
(16) Persistent, serious misconduct where other means of correction have failed to bring about proper conduct.
(17) Unauthorized preparation, giving, selling, transfer, distribution, or publication of any recording of an academic presentation in a classroom or equivalent site of instruction, including but not limited to written class materials, except as permitted by district policy, or administrative procedure.
(18) Violation of professional ethical code of conduct in classroom or clinical settings as identified by state licensing agencies (Board of Registered Nursing, Emergency Medical Services Authority, Title 22, Peace Officers Standards & Training, California Department of Public Health).

Narrative of Violation/Other Behavior of Concern *

Action You Have Already Taken *Indicate any intervention or action you have already taken.

Supporting Documents - "Click Here" to email any supporting documents.

The following action is requested:

None, FYI only.
Informal Consultation Referral

Formal Disciplinary Referral

Note: This form will be submitted to David Bransky, Assistant Dean of Student Services

Last Updated 9/16/10

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Ventura College Non-Harassment/Discrimination Policy