Study Distraction Incident Report Form
Please complete this form to report a study distraction incident. Your input helps us improve the study environment.
Your Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Date and Time of Incident
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Location of Incident
*
Please Select
Library
Study Hall
Dorm Room
Classroom
Cafeteria
Outdoor Area
Other
Type of Distraction
*
Noise (talking, music, etc.)
Electronic Devices
Interruptions by Others
Physical Discomfort
Environmental Factors (lighting, temperature, etc.)
Personal Stress or Fatigue
Other
Please describe the incident
*
How did this distraction impact your study session?
*
Minor interruption, quickly resumed focus
Moderate disruption, took time to refocus
Major disruption, unable to complete planned tasks
Other
Actions you took in response
Moved to a different location
Used headphones/earplugs
Asked others to lower noise
Reported to staff
Took a break
Did nothing
Other
Did you seek assistance?
Yes, from staff
Yes, from peers
No
Suggestions to prevent similar distractions in the future
Submit Report
Should be Empty: