Section 1: Student Information

Student Name:

Age:

Male:

College Year:

Student ID#
(DO NOT enter SS number):

Section 2: Incident Information 

Date:

Time:

Location:


1.


Nature of Incident
(choose one):
Student made a statement indicating suicidal thoughts or a threat to harm self but did not take any action. (If yes please go to questions 2 and 4)  
Student disrupted or intimidated others through “unconventional” or “bizarre” behaviors. (If yes please go to questions 2 and 4)  
Student was making statements or acting in a way that could be categorized as “unconventional” or "bizarre." (If yes please go to questions 2 and 4.)  
Student attempted to harm him/herself. (If yes please go to questions 3 and 4.)  
Student is using alcohol or other drugs in a way that is concerning to me. (If yes please go to questions 3 and 4)  
Student is just causing me general concern. (If yes please go to question 4)  

2.

Information about behavior/threat:
Briefly describe the events leading up to and surrounding the behavior/threat:



What was the nature of the behavior or statements? To whom were the statements or behaviors directed (if anyone)?  Why would you characterize them as “unconventional” or “bizarre”? 


What was the nature of the threat (if any)? To whom was it made? Was it verbal or written? What was communicated?


3:


4.

 

 
Reporter: 
Title or Relationship to Student:
E-mail:
Department: 
Phone Number: