C.A.R.E. Form UVM Community Reporting Form

Background Information

Please complete the following background information. While we don't require your name, in responding to these cases it is often very helpful to have the identity of the individual making the referral so we can follow-up most appropriately and make sure you are also supported. Residential Life staff members must complete all questions. Please note that students have the right to request a copy of any CARE Forms submitted on their behalf – if you would like to remain anonymous, please do not include your name or contact information.

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Preferred First and Last Name:

Your Role/Position::

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(i.e., student, peer, friend, roommate, faculty, RA, staff, relative, etc.)

Your Phone Number:

Your Email Address:

Email address must be of a valid format.

Res. Life Staff (Yes/No):

Urgency of this Report(Required):

This field is required.

Date of Incident(Required):

This field is required.

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if applicable.

Location of Incident(Required):

This field is required.

Specific Location:

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Add an on campus or off campus address, if applicable.

Involved Parties

Please list the individual(s) involved that you are concerned about, including as many of the listed fields as you can provide (Self-Reports are welcome).

Name of Student of Concern

Please indicate the role of the person involved.

ID Number

DOB (YYYY-MM-DD)

Phone Number

Email Address

Hall/Address

Questions

Please answer the following questions so that we can best support you and the person(s) you are concerned about.

We encourage you to share any relevant information with the CARE Team that you think is important, but please note that students have the right to request a copy of this form if they are listed as being involved. We encourage you to share information in the way you feel comfortable that is also respectful of the student whom you are referring for support. Please provide a detailed description of the incident/concern using specific concise, objective language (Who, what, where, when, why, and how).(Required) This field is required.

When did you first become concerned?(Required) This field is required.

If you are aware of any, please list any resources or supports with which this student has already connected regarding this matter. This field is required.

Acknowledgements(Required)

I acknowledge that the information I have provided here is, to the best of my knowledge, accurate and true. I acknowledge that I am aware that any students listed on this CARE Form have the right to request a copy of this form.

You must make at least one selection.

Supporting Documentation

Please attach any applicable documents, pictures, or other files. 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

Questions

Supporting Documentation

Submission