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Student of Concern Report Form


Does the person for whom you are creating a report pose an IMMEDIATE threat of harm to self or others? If yes, please call Campus Security IMMEDIATELY at 203-576-4911. if no, please proceed with the report below.

 

To submit an academic alert, please use CRM Advise via "MyUB Experience" here: https://experience.elluciancloud.com/uob99/ 

This form is for the use of University of Bridgeport students, faculty, staff or parents. Please provide detailed information regarding the concern you are reporting. Once the form is received, a member of the CARE Team (Concern, Assessment, Response, Evaluation) will review the information and take appropriate action, which may or may not include contacting the student, you and any witnesses you may have identified.

All Student of Concern reports are routed to the Office of the Dean of Students. If you provided contact information, a representative from the CARE Team may reach out to you for additional information. The goal of the CARE Team is to connect students to supports and services to promote their success and your assistance with this process may be important. If you did not provide contact information, please know that this may significantly limit our ability to respond to your concerns.

Background Information

Fields with a red asterisk are REQUIRED. All other fields are optional. In order to better assist our needs, we request that you provide us with your contact information so that we may follow up with you as needed.

 
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When was the last time you interacted with the student?

Student(s) Information

Please list the individuals involved (excluding yourself), including as many of the listed fields as possible that you can provide. Field may be left blank if the information is not known at the time of the report.

Involved party 1

Questions

The information you provide below is important in helping the CARE Team as they review and determine how to assist. Please provide factual and detailed information.

Does this student pose an immediate threat of harm to self or others? if yes, call campus Security IMMEDIATELY at 203-576-4911. If no, please proceed with the submission of this report.(Required)
This field is required.
Behavioral Concerns: Please select all that apply. The space to provide additional information is below.
You must make at least one selection.
Social/Emotional Concerns: Please select all that apply. The space to provide additional information is below.
You must make at least one selection.
This field is required.
What is your role in relation to the student?(Required)
This field is required.
Have you or others discussed your concerns with this student?(Required)
This field is required.
Is the student aware that you are reaching out to us for support?(Required)
This field is required.
How can we best support you?(Required)
This field is required.
How can we best communicate back to you as needed?(Required)
This field is required.

Supporting Documentation

Photos, video, email, and other supporting documents may be attached below. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

Submission