Office of the Vice President of Student Affairs
718-368-5563 (Phone)
718-368-4609 (Fax)
Assessment and Care Team Incident Report
Student First Name:  
Student Middle Name
Student Last Name  
Last 4 digits of SSN ID (if available):
Student Email Address (if available):

Your First Name:  
Your Last Name:  
Your Title:
Your Phone:  
Your KCC Faculty/Staff Email Address
(located on your KCC ID card):

Date of Incident:  format: MM/DD/YYYY
Time of Incident:  
Location of Incident:
Please provide a detailed description of the incident or nature of your concern: