Student of Concern

Required elements are in RED.
Section 1: Student Information
Student Name:
Student Age:
Student Gender:	Female Male
College Year:	Select One Freshman Sophomore Junior Senior Graduate Student
Student ID#:
Section 2: Incident Information
Date of Incident:	[None]
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. Information about self-harming/substance abuse behaviors Briefly describe what happened:
How was the incident discovered? Did the person seek help? From whom? Did someone discover him/her? Who?
How was the incident handled? By whom?Are parents or family members aware of the incident? Was the student hospitalized?Please list the names of anyone involved.
4. Please describe your general concerns and record any additional comments.
Reporter:
Title or Relationship to Student:
Email:
Department:
Phone Number:

Contact

Monnie Wertz, chair of the Student of Concern committee and assistant to the vice president of Operations and Planning, mhwertz@ut.edu, ext. (813) 257-3757, fax ext. 7253, or Stephanie Russell Krebs, dean of students, srkrebs@ut.edu, ext. (813) 253-6204, fax ext. 7458.