Behavioral Intervention Reporting
Incident Reporting Form

BEFORE YOU BEGIN:
If this is an emergency that involves an imminent risk of harm to self or others, please contact campus police at: 912-287-4027 or dial 911 prior to filling out this referral form.

Please provide responses to all the fields below.

 

Reporter Type:

   Do you wish to remain anonymous? Yes No (You'll be asked for your contact information later.)

 

Nature of Report:

 Academic Misconduct
Concerning Behavior
Medical Concern
Mental Health Issue
Non-Academic Misconduct
Odd or Eccentric Behavior
Personal Hardship Situation
Self-injurious Behavior behavior
Threatening Behavior behavior
Other-Specify in Incident Details
 

Urgency:
 

Were you personally threatened? 

Yes   No

Did you feel threatened at the time? 

Yes   No

Do you currently feel threatened? 

Yes   No

Did you see others threatened? 

Yes   No

 

Date and Time of Incident:

                       
 

Location of Incident:

  
   
Incident Details: