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ROCKFORD UNIVERSITY
BEHAVIORAL INTERVENTION & THREAT ASSESSMENT REFERRAL FORM
The Behavioral Intervention/Threat Assessment Team is NOT a crisis response team. If you believe a member of the Rockford University community is in danger, call Campus Safety & Security at 815-226-4060 or the Rockford Police Department (911) immediately.
This form is used to refer any member of the Rockford University community (students, faculty, or staff members) who are exhibiting concerning behaviors to the Rockford University Behavioral Intervention/Threat Assessment Team.
The Behavioral Intervention/Threat Assessment Team is an interdepartmental working group that coordinates the support services of Rockford University in order to assist community members who have displayed troublesome or disturbing behaviors. The Behavioral Intervention/Threat Assessment Team serves as a central network focused on caring prevention and early intervention for community members experiencing serious distress or engaging in harmful/disruptive behaviors.
The goal of this process is to offer the university community a tool or conduit in order to alert relevant campus authorities about their worry and concern of another member of the Rockford University community.
For additional information about the Rockford University Behavioral Intervention/Threat Assessment Team, please contact the Dean of Students at 815-226-3398.
Nature of this report:
*
Please select
Concerning or Threatening Behavior
Sensitive or Personal
Conduct
Other
Urgency of this report:
*
Please select
Critical
Normal
Information Only
Other
DESCRIPTION/NARRATIVE
Please provide a detailed description of the incident/concern using SPECIFIC concise, objective language.
Your description of the incident is important so please give as much information as possible.
REASON(S) FOR REPORT
Please check the most concerning behavior(s).
YOU ARE NOT REQUIRED TO CHECK ANY BOXES to complete the form; however, the categories below are a partial list (not inclusive) that may assist you in expressing your concerns about the individual you are referring.
Damage to Property (Personal or University)
Depressed mood, crying, withdrawn, lacking energy or motivation
Disorderly conduct
Disruptive behavior in a teaching environment or obstruction of University activities or activities on campus
Endangering health and safety of any person
Failure to comply with directions of university officials (Professor, RA, RHD, Security Officer, etc.)
Hazing
Illegal drug, alcohol, controlled substance use and/or distribution
Online harassment or intimidation
Physical or verbal abuse
Sexual harassment
Threats of harm to self (suicidal)/or other (Verbal or Written)
Threats of violence (direct or indirect)
Uncontrollable anger (physical fighting or severe rage)
Violation of law (campus, city, state, federal)
Weapons (possession of weapon)
Other
PERSON OF CONCERN
Please list the individual that you are concerned about, including as many of the listed fields as you can provide.
If you do not know the name of the person of concern, please include as much descriptive identifying information about the person as possible in the (previous) Description/Narrative section.
Person's Name
*
Person's Gender
PLEASE SELECT GENDER
Female
Male
Person's Role
Please select
Victim
Witness
Accused
Unknown
Person's Date of Birth
MM
/
DD
/
YYYY
Person's Phone Number
###
-
###
-
####
Hall/Address (If known)
Hall/Address
SUPPORTING DOCUMENTATION
Additional supporting documentation may be attached below. Maximum 12 megabytes per file. Attachments require time to upload, so please be patient after you click to submit this report.
Attach additional supporting documentation.
YOUR INFORMATION: Every effort will be made to maintain your confidentiality.
Your full name:
*
Your affiliation:
Please select
Student
Faculty Member
Staff Member
Your phone number:
*
Your e-mail address:
Your physical address:
Location of incident:
*
Please select
5100
Burpee
Clark Arts
Howard Colman Library
Kent Center
Lang Center
Lion's Den
Marland Physical Plant
Nelson Hall
Residence Hall
Scarborough Hall
Seaver Gym
Starr Science
Parking Lot
Outside, other than Parking Lot
Off Campus
Date of incident:
*
MM
/
DD
/
YYYY
Time of incident:
*
HH
:
MM
AM
PM
AM/PM
Specific location:
ADDITIONAL QUESTIONS
Is this your first time using the reporting form?
*
Yes
No
How did you hear about the Reporting Form? Select from drop down menu:
*
If other, please specify below
RU Website/Portal
Posted Signs
Staff/Faculty
Student
Other