Identify the person about whom you are concerned
His or Her Name:
*
His or Her Department:
His or Her Email Address:
His or Her Phone Number:
How do you know this person?
Identify Yourself
By identifying yourself, the Threat Assessment Team will be able to more fully investigate and respond to your concerns. Without your identifying information, we may not have enough information to address the situation you have described. Anonymous reports will be pursued, but the ability of the Threat Assessment Team to respond may be limited. Thank you for your referral.
Your First Name:
Your Last Name:
Your Email Address:
Your Phone Number:
Nature of Report
Please provide as much information as you can.
Primary Nature:
*
Choose One
Disruptive Behavior
Verbal Threat
Physical Threat
Threat of Self-Harm
Decline in Function
Emotional Distress
Other
Date of Incident:
Description of Concern or Incident:
*
Observations of Appearance or Behavior
Grooming/Hygiene:
Changes for the worse
Change of weight
Unkempt appearance
Odor
Emotional Signs of Distress:
Tearfulness/crying
Extreme mood swings
Shows no emotions
Seems to be hearing or seeing things
Physical Signs of Distress:
Bruising
Burns or cuts
Frequent injuries
Slurring words
Behavior in the Workplace
Often absent
Worsening performance
Often at odds with others or picks fights
Other Observations of Appearance or Behavior
General Observations
Issues reported or issues known to you (If a person appears ready to harm themselves or others, please immediately call 911 and report.)
If you are human, leave this field blank.