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.

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: *
Distressed, impaired ability to manage emotions




Disruptive or Threatening Behaviors




Please include detailed information of your observation such as frequency of behavior observed, 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: 6/28/2022

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

Your Email Address (Optional)

Your Phone Number (Optional)

Your Classification: