BEHAVIOR OF CONCERN
SUBMISSION FORM
Behavior to be Reported

Incidents considered emergencies or that require immediate intervention (harm to self or harm to others) should be reported to the Northeast State Police Department directly at 423.677.7927 (emergency cell) or by calling 9-1-1. Please include the name of the alleged perpetrator below if known.

First Name (if known) Last Name (if known)

Classification:

Location of Incident: *

Date of Incident: *

Time of Incident:

Description of Behavioral Concern

Please include detailed information of your observation such as frequency of behavior observed, witness willing to corroborate, day/time, location behavior occurred, etc. *

In what way does this behavior concern you?

Have you, or anyone else, taken any action to address your concerns or situation? If so, please describe.

Witnesses (if available)

Name Contact Information

 
Reporting Party

Today's Date: 10/22/2014

Your First Name (Optional) Your Last Name (Optional)

Your Email Address (Optional)

Your Phone Number (Optional)

Your Classification: