Community and Consultation Response Team

Southern University - Baton Rouge Campus

Student/Faculty/Staff Concern Referral Form

If you are concerned about a student and problems persists despite your efforts to intervene, please complete this form. The Office of the Dean of Students will follow-up with you regarding your concern. This form is to be used for the transmission of non-emergency information and is not seen as a substitute for continual conversation, nor will it become an official student conduct record. You will be notified of the disposition if/when appropriate.

In the event of an emergency, contact the SU Police Department at (225) 771-2770. NO ANONYMOUS FORMS ACCEPTED.

Student/Faculty/Staff Name:

Student ID Number

Your Name

Your Contact Information

E-Mail Address

Phone Number

Please list an optimal time of day to reach you.

Your relationship to this student/faculty/staff

Please list the date/time you observed the behavior that has prompted your concern

I am concerned because this person has: (check all that apply)

Not been seen in a number of days/has seemed to drop out of sight

Demonstrated erratic, or sudden changes in classroom performance.

Been distressed, hyperactive, withdrawn, depressed and anxious, and/or demonstrated mood swings.

Been uncharacteristically inattentive/unresponsive.

Been uncharacteristically angry/argumentative/aggressive.

Shown uncharacteristic behavioral, mood/attitude, and/or appearance changes.

Other concerns about the person or additional comments.