Email Background Information Your full name * Your position/title Your phone number Your email address * Your physical address Date of incident * Format: yyyy-mm-dd Time of incident Location of incident * Individuals Involved Please list the individuals involved (excluding yourself), including as many of the listed fields as you can. If there is no Kean ID # available, please provides as much information as possible to identify the student. When imputing an individual's Kean ID # please use all nine numbers. Person Name * ID Number Email address Select Role Student of concern WKUBIT ONLY Involved Victim Witness Staff Phone number Other Person Name Other ID Number Other Email address Other Select Role Student of concern WKUBIT ONLY Involved Victim Witness Staff Other Phone number Narrative / Description of Incident Please indicate the relevant section(s) that you feel may pertain to this report. You are not required to check any boxes to complete this form. You must make at least one selection* select Classroom disruption incl. unusual/bizarre behavior Crying spells Expressed anger or hostile actions/feelings Expressed seeing or hearing voices Feeling sad or depressed Hyper energy Loss in appetite Low energy Mood swings Office disruption incl. unusual/bizarre behavior Overly anxious or afraid Person acted in threatening manner Significant change in academic performance Significant change in appearance Significant change in behavior Sleepiness or falling asleep in classroom Strange or bizarre statements Writings or comments related to violence or self-harm Please describe the behaviors or actions that are concerning you. The description of the incident should be brief, precise, specific and chronologically accurate. Profanity and/or abusive language should be indicated. If you cannot remember specific information please indicate that as necessary. Hearsay and opinion are not appropriate inclusions for a statement. message Supporting Documentation Photos, video, email, and other supporting documents may be attached below. Allowed Types: jpg,jpeg,png,pdf,txt,docx,doc,mp4. 200M maximum total size. Attachments require time to upload, so please be patient after submitting this form. Choose files to upload
