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Care Team Referral

If you need to report an emergency, do not use this form. Instead, call the Old Dominion University Police at (757) 683-4000, or dial 911.

You may use this form to submit any concerns regarding the wellbeing of an ODU student. Please be sure to complete as much of this report as possible and provide your contact information in case a staff member needs to follow-up with you for more information.

This form is not intended to be used to refer a student through the student conduct process. To refer a student for a potential Code of Student Conduct violation, please click here.

If you are a student seeking information about how to request an Extended Class Absence or an Administrative Withdrawal, please visit Student Outreach & Support for more information and request forms.

Background Information

Your full name:

Your position/title:

Your phone number:

Your email address:

Email address must be of a valid format.

Date of incident(Required):

This field is required.

Time of incident:

Location of incident(Required):

This field is required.

Specific location:

Involved Parties

Please list yourself and the individuals involved, including as many of the listed fields as you can provide. For non-students involved in the incident, please list any available information.

Faculty should enter their ODU email address (minus the "@odu.edu") in the "Student UIN" field when adding themselves as an Involved Party.

Preferred Name

Gender

Role

Student UIN

DOB (YYYY-MM-DD)

Phone number

Email address

Address

Details of Referral

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.

Email me a copy of this report

Background Information

Involved Parties

Details of Referral

Supporting Documentation

Submission