Concerning Behavior Referral Form

Reporting Party Background Information

While anonymous referrals are accepted, you are STRONGLY encouraged to provide your name and contact information in order to allow BIT to most effectively address the concerning behavior.

Your Full Name:

Your Phone Number:

Your E-mail Address:

Email address must be of a valid format.

Nature of this Report(Required):

This field is required.

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Indicate the affiliation of the person exhibiting the concerning behavior.

Urgency of this Report(Required):

This field is required.

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If Urgent, consider calling University Police Department at (408) 924-2222, or dial 911.

Date of Incident(Required):

This field is required.

Time of Incident:

Location of Incident(Required):

This field is required.

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Begin typing the location to generate options or select

Specific Location:

Involved Parties

Provide identifying information about the student or employee of concern. Also include a contact for anyone else who may be willing to speak with BIT about similar concerns.

Name

Select Role

Student ID #

Phone Number

E-mail Address

Description of Behavior

Provide a detailed description of the incident/concern using specific, concise, and objective language. Include all relevant information, including who was involved in the incident, how each person was involved, what occurred, where the incident took place, and when the incident took place.

Incident Description(Required) This field is required.

When was the behavior first observed?(Required) This field is required.

If you or others have discussed these directly with them, how did the individual respond? This field is required.

What is your relationship to this individual? This field is required.

Is the individual aware that you notified the Behavioral Intervention Team (BIT) or informed other need to know staff at SJSU?(Required)

Yes No Not Sure

This field is required.

While the BIT will do our best to keep referrals confidential, there are times out of care, concern, and/or legal requirements it is necessary to identify the reporting party. If necessary, may we share your name with the individual?(Required)

Yes Not unless absolutely necessary

This field is required.

How would you like the BIT to follow up with you?(Required)

Phone E-mail Follow up not necessary

This field is required.

Supporting Documentation

Examples that capture student's own words: Assignments, zoom/canvas comments, PDFs of email, or screenshots from social media, etc. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

Email me a copy of this report

Reporting Party Background Information

Involved Parties

Description of Behavior

Supporting Documentation

Submission