PERSON OF CONCERN REPORT
Please hand deliver printable form to the UAM-CTC Public Safety Office, Room 106D, or in the Vice Chancellor’s Office,
 OR

Check Term: FALL SPRING SUMMER YEAR

Person of Concern:

What is the best way to contact this person?
Phone (If known):   Email (If known):

Report

The Office of Student Affairs seeks your help in identifying UAM community members who are in need of guidance and support. The purpose of this report is for you to be able to alert us to actions and behaviors that are causing concern. This report will not be used to cause disciplinary action, but rather to get help for the person.

Person Making Report:  Faculty   Staff    BIT    Other

Your Name:        Email:
Phone Number:

If you believe the student or the community is in immediate danger, please contact the Department of Public Safety at
870-364-6414 ext. 146.

Please indicate all that apply.

Academic   Family Issues   Alcohol/Drug Misuse   Physical Issues   Mental Health Issues

Eating Issues  Adjustment    Self-Injurious Behavior     Weapons        Verbal Aggression

Physical Aggression    Inappropriate Interests    Suicidal     Disrupting Classroom

Student Writings     Physical Stalking     Cyber Stalking and Harassment

Have others shared with you concerns about this person: YES      NO

Please comment on the concerning behavior:

What, if anything, have you done to address this concern?

Do you wish to remain anonymous to the person of concern? Yes    No

(If you do wish to remain anonymous, the chairperson of the team may still contact you for further information)

Evidence to suggest false or misleading reports with intent to defame the character of another may result in disciplinary actions.

For UAM BIT Use Only

Student Address: _________________________________ E-mail: _______________________ Phone Number: _____________________

Action Required Yes / No

Goal: __________________________________________________________________________________________________________

Intervention recommended: __________________________________ Conducted by: Date:___________

Follow-up: _____________________________________________________________________________________________________

_________________________________________________________________________________________Date:__________________