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Student of Concern

Required elements are in RED.
Section 1: Student Information 
Student Name:
Student Age:
Student Gender:  
College Year:  
Student ID#:
Section 2: Incident Information
Date of Incident:  [None] Select a Date Delete the Date  

1. Nature of Incident (Choose One):


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.

Title or Relationship to Student:
Phone Number:


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