Individuals who are concerned about a student and are seeking assistance in supporting that student are encouraged to report their concerns through the following form. Members of the CARE Team will in turn work with you to provide outreach and support to the student. If you have a concern about a student, please know that confidentiality laws do not prevent you from reporting the concern. IF THERE IS IMMEDIATE RISK TO LIFE OR PROPERTY please call 911. Please complete the form as thoroughly as possible, this helps us support you and the student(s) as quickly as possible.Background InformationYour full name: First Middle Last Your telephone number:(Required)Your email address:(Required) Enter Email Confirm Email Urgency of this report:(Required) Normal Critical Location of Incident:(Required) Off-Campus Residence Hall Academic Building Please Specify:(Required)Name of Student(s) in which you are concerned: First Last Name of Student(s) in which you are concerned: Name of Student(s) in which you are concerned: First Last ID NumberStudent Concerning Behavior / Concern for StudentPlease select the following concerns that have been observed. Providing detailed description of the incident or concern will help the CARE Team better address your concern.Academic Concerns (please select all that apply): Repeated absence Noticeable change in academic performance Failure to respond to faculty/staff outreach Disturbed writing Other (please specify in narrative below) Emotional Concerns (please select all that apply): Inappropriate emotional outbursts (unprovoked anger/aggression, hostility or sobbing) More withdrawn or more animated than usual Expressions of hopelessness or worthlessness Expressions of severe anxiety or anxiousness Other (please specify in narrative below) Social-Cultural Concerns (please select all that apply): Food insecurities Housing insecurities Financial insecurities Feeling of not belonging and/or lack of support in campus environment Other (please specify in narrative below) Behavioral Concerns (please select all that apply): Written or verbal statements which mention despair, suicide, or death Severe hopelessness, feeling of sadness, isolation, and withdrawal tatements such as “going away for a long time’ made by student Direct statements indicating distress Other (please specify in narrative below) Professional Concerns (please select all that apply): Death of a family member Death of fellow student Death of non-student/other Student impacted by an event Unable to locate student Statements indicating family problems or other personal loss Other (please specify in narrative below) Please tell us about your relationship to this student.(Required) I am self reporting I am a fellow student I am their roommate I am their friend I am a coworker I am a parent/relative I am a faculty member I am a staff member I am a clergy member I have a relationship with this student not described above Please provide a detailed description of the behavior or situation that led you to be concerned about the student. Sharing observations and facts are more useful than characterizations or labels.(Required)Is the student aware you are reaching out to the CARE team for assistance and supporting them?(Required) Yes No How can we best communicate back with you regarding your concern for this student?(Required) I prefer email. I prefer a telephone call. I prefer to set up a meeting. I’m confident the CARE team will follow up with this student and am not seeking communication back. Supporting DocumentationMax. file size: 50 MB.Photos, video, email, and other supporting documents may be attached below. TweetShareShare
