Name First Last Position / Title PhoneEmail Address Street Address City Nature of this reportConcerning behaviourThreatening behaviourRecent change in behaviourRecent change in appearanceUrgency of this reportCriticalUrgentNormalDate of incident - must be mm/dd/yyyy format MM slash DD slash YYYY Time of incident : Hours Minutes AM/PM AM PM Location of incident Person of ConcernPlease provide as much information as possible about the Individual, Faculty or Staff who is exhibiting concerning behavior.Person Name GenderMaleFemaleOtherRole ID Number Date of Birth - must be mm/dd/yyyy format MM slash DD slash YYYY PhoneEmail Hall/Address Additional InformationSpecify behaviors applicable to the person of concern (select all that apply):Academic Behaviors Deterioration in quality of work Repeated absences from class or work coupled with signs of distress Disorganized or erratic performance or behavior Person sending frequent, lengthy, "ranting", or threatening types of emails to professor or TA Disturbed writing Physical Behaviors Dramatic change in energy levels (either way) Worrisome changes in hygiene or appearance Frequent state of intoxication (alcohol or drugs) Self-mutilation (noticeable cuts or burns) Emotional Behaviors Inappropriate emotional outbursts (unprovoked anger/aggression, hostility or sobbing) Exaggerated personality traits (more withdrawn or animated than usual) Expressions of hopelessness, fear or worthlessness Direct statements indicating distress Suicidal remarks Impulsiveness Paranoid behavior Other Behaviors Makes direct threats Makes veiled threats Stalking Inappropriate interest in weapons Description of behavior. Describe in detail any incidents in which the individual referenced above exhibited concerning behavior. Provide specifics such as dates, times, locations, individuals involved and the person's demeanor at the time of the contact.Description of behavior. Describe in detail any incidents in which the individual referenced above exhibited concerning behavior. Provide specifics such as dates, times, locations, individuals involved and the person's demeanor at the time of the contact.Duration of Behavior? Single Incident On-going When was the behavior first observed? Please provide names and contact information of others who may have seen the incident or behavior.Please provide any information about the individual that may be helpful to the Behavior Intervention Team as they try to assist the individual. If none, please write NAPlease describe any action you may have taken to address the concerning behavior and how the individual responded to your attempts. If none, please write NAFileMax. file size: 60 MB.CAPTCHA