Campus Life

Behavioral Incident Referral

This Behavioral Incident Referral is designed to enable faculty, staff and students to voluntarily report behaviors that may raise concerns about a student’s safety, or pose a threat to another student. The referral provides a mechanism for alerting staff to potential concerns, helping them to respond to individual incidents and assisting them in finding patterns of behavior that might indicate growing problems.  An incident, in this context, is an event that does not warrant immediate intervention.  In the event of an emergency or crisis situation that requires immediate intervention, call 911.
(Please enter as much information as possible)
Name of Student of Concern
Incident Information:
Date and approximate time of incident
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Date form completed
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Class/Location of incident
* Name of person making referral
Email address
Are you a
if other please explain
Name(s) of others involved or witnesses
Incident explanation

Please provide a detailed description of the incident, paying particular attention to the behaviors of the student. Concrete, specific observations are most useful. Avoid providing judgments, assessments and opinions:
(Note any known relevant history—mental health, alcohol/drug use, etc.)


Please describe conversations you have had with the student and any action you have taken regarding this incident:

* Individuals are allowed to make anonymous reports, however, if a name is not provided it may hamper the team’s ability to seek follow up information that may be critical in determining an appropriate course of action. If a name is provided, the team will provide feedback regarding actions taken, and will do all they can to maintain one’s confidentiality although it cannot be guaranteed.
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