Report a Concern
If you are concerned about the health, well-being or safety of a yourself, another student, faculty member or staff member please fill out all possible fields on this form.
Contact Information
All reports will be treated with discretion. Information from this form may be shared with appropriate individuals in order to help protect the safety and health of those involved in any incident. You may remain anonymous when reporting through this form. However, it’s very helpful to have your contact information and name in case there is a need to obtain more information about the situation or clarify information. Every attempt will be made to review and address the concerns you submit on this form, but without adequate information, the college may not be able to respond as effectively. Therefore your contact information is strongly encouraged.
Your name:
First Name
Last Name
Your e-mail
example@example.com
Your phone number
Format: (000) 000-0000.
Your S#
I am a
Please Select
Student
Faculty/ Staff
Coach
Visitor
Person of Concern
Please fill in as much information as possible. LEAVE INFORMATION BLANK IF UNKNOWN.
If you are referring yourself, please check this box. You can skip the contact information for the "Person of Concern" area
self-referral
Person of Concern's Name
First Name
Last Name
Is the person you are referring a:
Please Select
Student
Faculty
Staff
Person of concern's email:
example@example.com
Person of concern's phone number:
Format: (000) 000-0000.
Person of concern's S#
Your Concern
Nature of concern:
Please Select
Health-care need
Mental health need
Suicidal/ Potential for self-harm
Potential of harming others
Student is in danger of being harmed
Food needs
Clothing needs
Shelter/ Housing needs
Academic issue
Alcohol
Bullying
Discrimination
Complaint
Disorderly conduct
Drugs
Fire Safety
General Safety
Noise
Pets
Guests/ Visitors
Room mate conflict
Sexual misconduct
Smoking
Solicitation
Trash
Theft
Weapons
Urgency of your concern
Please Select
Normal
Urgent
Date of incident
-
Month
-
Day
Year
Date
Time of incident
Hour Minutes
AM
PM
AM/PM Option
Location of incident
Please Select
On-campus
Off-campus
Specific location:
Descriptions/ Narrative
Please describe your concerns in as much detail as possible. Use the person’s name, when known, rather than using pronouns (i.e., he, she, they, etc.) to identify people in your description. Indicate the specific words, phrases, interactions, or behavior that prompted this report.
Submit
Should be Empty: