Southern University and Agricultural and Mechanical College

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Community and Consultation Response Team


       Southern University - Baton Rouge Campus 

      Student/Faculty/Staff Concern Referral Form  




If you are concerned about a student, faculty/staffand problems persists despite your efforts to intervene, please complete the form below. A member of the Community and Consultation Response Team (CCRT) 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 a record with the Office of Student Conduct, or Human Resources (HR). You will be notified of the disposition if/when appropriate. Information shared with the committee falls under the purview of the University Counseling Center (UCC).

This committee does not function after hours or during university breaks. In the event of an emergency, contact the SU Police Department at 225-771-2770. NO ANONYMOUS FORMS ACCEPTED.

Thank you in advance for your care and assistance.

Student/Faculty/Staff Name:

(First Name)

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Been distressed, hyperactive, withdrawn, depressed and anxious, and/or demonstrated mood swings.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