Reporting Form Reporter InformationYour full name: If you wish to remain ananoymous, typeYour Position/Title: If you are a faculty/staff member, please include your title. If you are not, typeYour Phone Number:Your email address: Date of Incident:(Required) MM slash DD slash YYYY Time of Incident: Hours : Minutes AM PM AM/PM Location of incident:(Required) Where did the incident you are reporting occur?Specific Location: Is there anything else we should know about the location?Involved PartiesName or Organization Select RoleStudent exhibiting concerning behaviorWitnessQuestionsPlease describe the behaviors that have prompted you to share your concerns. Please use as much detail as possible, including dates for any specific concerns. If the concern involves threats or comments related to self-harm or harm to others, please include exact quotes and how these comments were communicated).(Required)Based on the description you provided, please check any behaviors below that have led you to be concerned about the individual involved (optional). Academic Stress Domestic Violence Physical Attack Bizarre/Disjointed Thoughts Excessive Anxiety Property Damage Communicating Threats Extreme Mood Swings Sexual Assault Cutting Behaviors Family Stress Significant Change in Appearance/Behaviors Dating Violence Financial Stress Stalking (incl. Cyber Stalking) Depressed/Persistent Sadness/Unexplained Crying Homicidal Ideation Suicidal Ideation Display or Use of Weapon Inappropriate display of Anger/Negative Emotions Suicide Attempt Disruptive Classroom Behavior Intimidation Unexplained Absences (after multiple contact attempts) Disturbed Eating Behaviors Involves Alcohol/Drug Use Disturbing written material/class discussion Obsessively Suspicious/Paranoid Please list any other Louisiana Christian University departments or outside agencies that were contacted about the concerns you have shared (optional): I understand that referrals from this form will be received during normal business hours (Monday-Thursday, 7:45 AM - 5:00 PM, and Friday, 7:45 AM - Noon) and are not monitored after hours, on weekends, or during official Louisiana Christian University holidays. Please contact campus security at 318-487-7233 or 318-308-6505 if there is an immediate risk of harm to self or others prior to submitting this form.(Required) Yes, I understand. Supporting DocumentationIf you have any supporting documentation, such as images or other files, please submit them here. Attachments require time to upload, so please be patient after submitting this form.Max. file size: 512 MB. Email me a copy of this report
