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 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:

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Been distressed, hyperactive, withdrawn, depressed and anxious, and/or demonstrated mood swings.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