Care Team Reporting Form

If you are an employee and are injured while on duty, contact Human Resources immediately or call 855.339.1893.
Cares Report

Please leave contact information blank if you would like to remain anonymous; keep in mind that anonymous reporting may limit the ability of the Care Team to fully investigate the concern.
Purpose

The purpose of this form is to give the SouthArk community the ability to report concerning, disruptive, alarming, or threatening behavior as well as injuries, accidents, and medical emergencies. This form is not expected to be completed first during an emergency; It is to be completed as soon as possible after the emergency has been addressed by appropriate personnel.
If an incident is currently a threat to physical safety, please report directly to the Department of Public Safety by dialing 999 or using a security phone if on campus; 870-866-9208 if off-campus.

When to Use This Report

Reportable behaviors, accidents, injuries, or illnesses can include an emotional disturbance, food insecurity, sudden illness such as fainting, a fall with injury, sexual or other misconduct, or any concern you have for a member of our community that you want a member of the team to reach out to or that may require medical attention. The Care Team will use the report to identify, assess, intervene, and respond to the situation. Although written notice is preferred via this form, if you have any problems or concerns with this form or you wish to make this report in person, please contact CaresReport@southark.edu for instructions on next steps. This report will also serve to inform the respective cabinet member(s).
Reporter's Name

First NameLast Name
Reporter's primary role at SouthArk
Reporter's Phone Number
Please enter a valid phone number.
Reporter's Email
example@southark.edu
Reporter's Physical Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Reporter's Mailing Address (if different from physical address)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Please provide information related to your concern below.
Event Classification

Concerning Behavior, StudentConcerning Behavior, EmployeeConcerning Behavior, 3rd partyIllness/Accident/Injury
Date the change was first noticed or the incident occurred*

MonthDayYear
Date
Time of the event or precipitating behavior if applicable:
Location of the event:
Specific location the event occurred if applicable (list address if known for off campus events)

Person of Concern and Witnesses
Involved Party*
Please provide a description of the behavior, concern, accident, illness, or injury. The narrative should be as detailed as possible.*
Attachments require time to upload, so please be patient after submitting this form.

Cancelof
If you are the victim, do you want SouthArk to notify your next of kin with details of this report? If you are not the victim, select "Not Applicable".*
Next of Kin
Important

If you are a victim and would like an investigation or assistance, you must sign below and provide your contact information above. Supportive measures will always be offered to victims regardless of a signature below or whether an investigation occurs.
Signature
Should be Empty:

Important