Behavioral Concern Reporting Form

Student Referral System

Behavior to be Reported

If this incident is an emergency or requires immediate intervention (behaviors causing harm to self or harm to others), contact the Northeast State Police Department directly at 423.677.7927 (emergency cell) or call 9-1-1. Timely Warnings or Emergency Notifications may be necessary to alert the campus community to potential danger.

Behaviors of Concern are defined as those behaviors that seem questionable, suspicious, or inappropriate to the situation. Please include the name and contact information if known of the person exhibiting the behavior of concern.

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

Classification:

Location of Incident:

Date of Incident:

Time of Incident:

Phone Number: (if known)

Email Address: (if known)

Description of Behavioral Concern

Check all that apply: *
Disruptive, Belligerent, or Inappropriate Behavior Impairment of Thoughts Lack of Anger Management or Overly Aggressive Behavior Low Frustration Tolerance or Overreaction to Circumstances Notable Change in Behavior, Appearance, or Emotional Reactions Paranoia Verbal or Written References to Violence, Harm to Self, or Harm to Others Violation of the Student Code of Conduct Person Self-Disclosed the Behavior or Incident Other, please specify:

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

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

Witnesses (if available)

Name	Phone Number or Email Address

Reporting Party

Today's Date: 4/19/2019

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

Your Email Address (Optional)

Your Phone Number (Optional)

Your Classification: