Report a Concern

Reporting Party Information

While anonymous reports are accepted, you are STRONGLY encouraged to provide your name and contact information in order to allow us to most effectively address the concerning behavior.

Your full name:

Your position/title:

Your phone number:

Your email address:

Nature of this report:*

Date of incident:*

Time

:

Location of incident:*

Specific location:

Person of Concern

Please provide as much information as possible about the Student, Faculty or Staff who is exhibiting concerning behavior.

Name

Select Gender

Select Role

ID Number

DOB (YYYY-MM-DD)

Phone number

Email address

Additional Information

Specify behaviors applicable to the person of concern (select all that apply):

Academic Behaviors

Deterioration in quality of work
Repeated absences from class or work coupled with signs of distress
Disorganized or erratic performance or behavior
Person sending frequent, lengthy, "ranting", or threatening types of emails
Disturbed writing

Physical Behaviors

Dramatic change in energy levels (either way)
Worrisome changes in hygiene or appearance
State of intoxication (alcohol or drugs)
Self-mutilation (noticeable cuts or burns)

Emotional Behaviors

Inappropriate emotional outbursts (unprovoked anger/aggression, hostility or sobbing)
Exaggerated personality traits (more withdrawn or animated than usual)
Expressions of hopelessness, fear or worthlessness
Direct statements indicating distress
Suicidal remarks
Impulsiveness
Paranoid behavior

Other Behaviors

Makes direct threats
Makes veiled threats
Stalking
Inappropriate interest in weapons

Description of behavior. Describe in detail any incidents in which the individual referenced above exhibited concerning behavior. Provide specifics such as dates, times, locations, individuals involved and the person's demeanor at the time of the contact.*

Duration of Behavior?*

Single Incident
On-going

If ongoing, when was the behavior first observed?

Please provide names and contact information of others who may have seen the incident or behavior.

Please provide any information about the individual that may be helpful to the Behavior Intervention Team as they try to assist the individual. If none, please write NA*

Please describe any action you may have taken to address the concerning behavior and how the individual responded to your attempts. If none, please write NA*

Supporting Documentation

Photos, video, email, and other supporting documents may be attached below. Attachments require time to upload, so please be patient after submitting this form.

Max. file size: 32 MB.

Reporting Party Information

Person of Concern

Additional Information

Supporting Documentation

Authors

Other Information related to Safe Wayne