Purdue University Northwest Logo

Student of Concern Report


In the event of an emergency, call 911


This form is to be used to report a person of concern to the Office of the Dean of Students. Please complete as much information on this form as you can. Depending on the situation described, the Office of the Dean of Students' Student Advocacy Team will reach out to the student for support and to provide resources. If the situation described is a cause for critical concern, the report may be forwarded and reviewed by members of the university's Student Behavioral Intervention Team .
If you have a concern about a student, please know that confidentiality laws do not prevent you from reporting the concern.

Forms submitted after 4:30pm on Monday through Friday and on weekends, will be processed the next business day. If this is an immediate concern please call the Purdue University Northwest Police Department for the Hammond Campus 219-989-2220 and for the Westville Campus 219-785-5230.

Any item with a red asterisk (*) is required.

Reporter Information

 
Enable additional features by logging in.
Learn more
Professor for XXX105 course, Best Friend, Parent
Email address must be of a valid format.
This field is required.
This field is required.
This field is required.

Involved Parties

Provide as much information as possible to ensure proper identification of the individual.

Involved party 1

Specific Information

Please be as detailed as possible in answering the following questions. You will also have the opportunity to upload any supporting documents at the end.
Please note that this report is not intended to initiate a conduct process. It is solely focused on responding to concerning behavior and providing help.




Please indicate any of the following concerns that you have observed or have been reported to you about this student:

Academic Concerns (please select all that apply):
You must make at least one selection.
Emotional Concerns (please select all that apply):
You must make at least one selection.
Social-Cultural Concerns (please select all that apply):
You must make at least one selection.
Behavioral Concerns (please select all that apply):
You must make at least one selection.
Personal Concerns (please select all that apply):
You must make at least one selection.
This field is required.
This field is required.
Is the student involved in any student support services? Examples: PNW Accessibility Center, Purdue Northwest Counseling Center, Veteran Services, Educational Opportunity Programs(EOP)/TRiO(Required)
This field is required.
Is the student aware you are reaching out to the Dean of Students team for assistance supporting them?(Required)
This field is required.
How can we best communicate back with you regarding your concern for this student? If you would like us to reach you, please be sure contact information at the top of the form is accurate.(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.

Select copy recipients

If you would like the other offices mentioned in this report to receive a copy of this information, please select the office below:
If you would like the other offices mentioned in this report to receive a copy of this information, please select the office below:

Submission