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
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 filling 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.

Person being referred:

First Name:

Last Name:

If Known:

Street Address:

City:

State:

Zip:

Phone Number:

Date of Incident:

Time of Incident:

Location of Incident:

What was the nature of the incident?

Was there any direct threat of harm to others?

Yes No

Please describe:

What was the resolution of the incident?

Was campus security involved?

Yes No

What is the case number?

Were there any background causes or reasons for this incident?

Was this person involved in previous incidents?

Yes No

Please describe:

Information about the originator of the report:

First Name:

Last Name:

Phone Number (if known):

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 Health and Safety Referral Working Group?

Yes No