Student of Concern From

Student of Concern Form

This form is a NON-EMERGENCY reporting form. Do not use this form to report events that present an immediate threat to health or safety. For emergencies, call LSSU Public Safety at 906-635-2100 or 911.

Thank you for taking your time to share your concerns with the Behavioral Concerns Team (BCT). By sharing your concerns, you are helping LSSU identify an individual who may need guidance and assistance in safely navigating potential emotional, personal, and academic concerns. in the event that what you report constitutes a Title IX concern, please know that the BCT is required to follow mandatory reporter guidelines and forward your report to the Title IX office for appropriate review and follow-up.

Please complete this form as comprehensively as you are able, including all information that is known to you.

Your Name*

First Name

Last Name

Your Email Address*

Your Phone Number

Name of student*

First Name

Last Name

Student's LSSU Email*

Student's A#*

Student's Year (e.g., freshman, sophomore, etc.)*

Residence*

On-Campus Off-Campus

If on campus, list your hall and room/apt#

If on campus, list the names of your roommates:

Below, please provide the date, time, and location of the incident. Also, provide a brief, concise narrative describing your concerns, using objective language. When submitting a behavioral referral, it is important that you identify an observed behavior. Knowledge of a student's disability, mental or medical diagnosis, history, etc., does not qualify as behaviors. Please refrain from using medical or mental health diagnoses unless explicitly self-reported by the student of concern.

Date/Time of observed incident*

Location of observed incident/behavior*

On-campus Off-campus

Other:

Student of Concern Behavior Details

Please share as much information as you can on the student and his/her/their behavior.

Please include the student of concern and all parties that were involved and/or present at the time of the incident.

Involved parties include others who were present at the time of the incident, involved with the student of concern, or impacted by the behavior of the student of concern.

Description of incident/behavior*

Duration of behavior*

Single incident Ongoing behavior

If ongoing, how long?

If ongoing, when was the behavior first observed?

If ongoing, does it seem to be getting worse or more frequent?

Was LSSU Public Safety or another law enforcement agency notified?*

Yes No Unsure

Supporting documentation

No File Chosen

File uploads may not work on some mobile devices.

Please include all relevant documentation (e.g., image, attachment, document, etc.), if applicable.

What interaction or communication have you had with this student to address your concern? If none, please type N/A.

Communication/interaction type:*

Is the student aware that a referral is being submitted on their behalf?*

Yes No Unsure

FERPA Statement

We understand that it is not always feasible or comfortable to inform a student in advance that you are making a referral. Please not that submitting this Form will generate an education record for the identified student, and, under FERPA, a student may review their education records after submitting a written request.

In the event that the BCT has additional questions, which of the following methods of communication is preferred (check all that apply):*

Phone Email In person meeting I prefer NO contact from the BCT.

Understanding

I understand that this report will only be reviewed during normal business hours, Monday - Friday 8:00 AM to 5:00 PM. If I believe there is an immediate risk of harm to self or others, I will contact LSSU Public Safety at 906-635-2100 prior to submitting this report.

I understand the above statement.*

I acknowledge the above statement. I do not acknowledge the above statement.