Complete the form. In the last box, please provide a detailed description of your concern using specific, concise, objective language. This statement will be forwarded to the Student Conduct Office, 425 Wells Hall. For additional information please contact Dr. Don Robertson at or call 270.809.6839.

Student Full Name (First, Middle, Last):

M Number (if available):

Student Email Address (if available):

Your Name:

Your Phone:

Your Email Address:

Date and Time of Incident: (if applicable)

Location of Incident: (if applicable)

Basis of Concern:*