*Required Field

Name of Student:

L# (if known):

Gender:

Student Contact Information (if known):

Date and Time of behavior(s) of concern:

Place(s) of behavior of concern (location):

Description of behavior of concern:
Please provide an objective description of behavior or situation(s) that have caused you concern. Be as specific as possible about behaviors you have observed. The student will have a right to see the Student of Concern Report. Any information you share on the Student of Concern Report may be used in a student conduct hearing if the student's behavior violates the University of Nevada Las Vegas Student Conduct Code.

Attach any supporting documentation or materials if appropriate.

Submitted By:*

Date:

Phone:

Email:*

Relationship to Student: