Behavioral Concern Report

Please check to acknowledge the following:*

I understand that this is not an emergency

Person Submitting Report:

First name

Last name

Email

Phone number

College affiliation*

Person Exhibiting Behavior of Concern:

First name*

Last name

Email (if known)

Description of Behavior of Concern:

Date of incident*

Time of incident

Location of incident

How frequently does the person exhibit the behavior your concerned about?

1 time

2-4 times

5+ times

Detailed description of behavior*

Have you discussed your concerns with this person?*

Yes

No

If you answered "Yes" above, please explain how you addressed your concern, as well as any response you received.

You can choose for your identity to remain private, or select how involve you would like to be.

I wish to remain anonymous, if possible

I don't want to be involved, but I want to know my concern was addressed

I want to be contacted by a member of the BIT for more consultation

I would like to be involved, as appropriate, with addressing this concern.

(Check all that apply)

Thank you for taking the time to report this concern. We appreciate your willingness to come forward. You will receive a response within 24 hours if you provided your contact information.

Behavioral Concern Report

Behavioral Concern Report

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