Person of Concern Health and Safety Referral

Do not use for immediate Crisis/Emergency
Call 911 or campus law enforcement at (719) 549-2373

If you are concerned about the health, well being, or safety of any individual on campus, you may complete this form.

Examples of why you may fill out the form include persons who are:

Harmful to themselves or others
Making suicidal threats or gestures
Exhibiting alcohol or drug problems
Exhibiting a pattern of bizarre behaviors or actions
Experiencing hospitalization for psychiatric, drug or alcohol problems
Disruptive to the living or learning community

This is obviously not a complete list, but should give some idea of types of issues of concern.

Please complete the form if you have any reason to worry about a person's health or safety. This form is designed to help the person you are concerned about, not to punish him or her. You may remain anonymous and still submit this report, so you do not need to fear negative consequences to you for filling this out. The form will be reviewed in order to determine the best way to help manage the situation. This could include meeting with the person filing out this form or contacting the person of concern.

Answer as best you can. Fill out as many of the following questions as you can.

Items indicated with the are required fields to process your request.

Person being referred:

First Name:

Last Name:

If Known:

Street Address:

City:

State:

Zip Code:

Phone number:

Example: (xxx) xxx-xxxx

Date of incident:

Time of incident:

Location of incident:

What was the nature of the incident, e.g., threat or self harm, problematic behavior?:

Chars.

Was there any direct threat of harm to others?

Yes No

What was the resolution of the incident, e.g., stabilized by friends, faculty, staff, or campus security, etc.?

Chars.

Was campus security involved?

Yes No

Were there any background causes or reason for this incident?

Chars.

Was this person involved in previous incidents?

Yes No

Information about the originator of the report:

First Name:

Last Name:

Phone number (if known):

Example: (xxx) xxx-xxxx

Title or relationship to the person:

Additional copy of this report should go to:

Have you discussed this referral with the person?	Yes No
Would you like to remain anonymous?	Yes No
Would you like a contact with the Chair of the Person of Concern Working Group?	Yes No

Person of Concern Health and Safety Referral

Do not use for immediate Crisis/Emergency Call 911 or campus law enforcement at (719) 549-2373

Person being referred:

Information about the originator of the report:

Do not use for immediate Crisis/Emergency
Call 911 or campus law enforcement at (719) 549-2373