Student Response Team Incident Reporting Form

    • This form can be used for the following:

      1) Concerns about a student's mental state and well-being.
      2) To help provide referral and resource information or to provide counseling/resources.
      3) Concerns about disruptive or inappropriate behaviors in the classroom or on campus.
      4) Concerns about a student representing a threat to themselves or others.
      **If there is an immediate emergency, please call 9-1-1 or Public Safety at 719-255-3111

      All fields marked with (*) are required. You may choose to remain anonymous, but your identity may help us in the investigation.

    • Your Name
       
       
    • I am a*
    • If Faculty/Staff, please indicate office or department affiliation
    • How to Contact You

    • Email Address
    • Phone Number
    • Preferred way to contact you*
    • Incident Report

      Please be as detailed as possible. The more information, the better we can assist you.

    • Student(s) Being Referred*
      Name, Email if known
    • Student ID#
      If known
    • Date(s) of Incident*
    • Type of Concern*
    • Please Describe the Incident*
    • Witness(es)
    • Was there a direct threat to self or others?*

If there is an immediate emergency, please call 9-1-1 or Public Safety at 719-255-3111