Camden Student Concern Report

Background Information

Please provide detailed information regarding the incident you are reporting.

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Your full name:

Your position/title:

Your phone number:

Your email address:

Email address must be of a valid format.

Urgency of this report(Required):

This field is required.

Date of incident(Required):

This field is required.

Time of incident:

Specific location:

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Registrar's Office, Dining Hall, Computer Lab, etc.

Involved Parties

Student's Name

RUID Number

Phone number

Email address

Hall/Address

Reason for Report/Areas of Concern

Please describe and check the reason(s) for your report. Feel free to check as many as applicable.

Please provide a detailed description of the incident/concern using specific, concise language. If you have listed an individual as involved, they should appear at least once in the narrative.(Required) This field is required.

Academic Concern:

Concern with grades

Concern with professor

Concern with classmate

Concern with technology

Concern with class absences

Concerned with class performance

Other (please describe in narrative section)

You must make at least one selection.

Behavioral Concern:

Disruptive behavior in classroom or public space

Inappropriate display of anger or negative emotions

Use of dangerous drugs (such as heroin, prescription drugs)

Student missing (contact police)

Student unresponsive to outreach

Wellness Check (contact RUPD)

Other (please describe in narrative section)

You must make at least one selection.

Financial Concern:

Concern with Financial Aid

Concern with personal finances

Concern with Bursar/Student Accounting

Concern with term bill

Other (please describe in narrative section)

You must make at least one selection.

Personal Concern:

Personal tragedy, incident event that adversely affects a student's performance/attendance

Death in the family

Long-term illness (family or self)

Housing insecurity/Homelessness

Food insecurity

Other (please describe in narrative section)

You must make at least one selection.

Semester Withdrawal / Incomplete Semester:

For academic reasons

For financial reasons

For medical reasons

For military leave/deployment

Other (please describe in narrative section)

You must make at least one selection.

Social/Relationship:

Concern with student organization

Concern with peer connections

Concern with campus involvement

Concern with partner/significant other

Other (please describe in narrative section)

You must make at least one selection.

Have any referrals already been made?

Yes No Unsure

You must make at least one selection.

If referrals have been made, please list where the student has been referred: This field is required.

How would you like to receive follow-up:(Required)

Phone Email Do Not Contact Me

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.

Email me a copy of this report

Background Information

Involved Parties

Reason for Report/Areas of Concern

Supporting Documentation

Submission