Behavior Threat Concern / Incident Report

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Concern / Incident Report Form

If you believe a person may pose a threat of imminent danger to him/herself or to others, call 911 and then contact the office of campus security at 903-563-1417

Identify the person about whom you are concerned

Their Name

Their Department

Their Email

Their Phone

How do you know this person?

Identify Yourself

By identifying yourself, the Behavior Assessment and Intervention Team will be able to more fully investigate and respond to your concerns. Without your

identifying information, we may not have enough information to address the situation you have described. Anonymous reports will be pursued, but the

ability to respond may be limited. Thank you for your referral.

Your Name

Your Email

Your Phone

Nature of Report

Please provide as much information as you can.

Primary Nature:

Date of Incident:

Description of Concern or Incident

Are there other witnesses to the concern or incident?

Observations of Appearance or Behavior

(select all that apply)

Grooming/Hygiene

Changes for the worse

Change of weight

Unkempt appearance

Odor

Emotional Signs of Distress

Tearfulness/crying

Extreme mood swings

Shows no emotions

Seems to be hearing or seeing things

Physical Signs of Distress

Bruising

Burns or cuts

Frequent injuries

Slurring words

Behavior in groups/class/workplace

Often absent

Worsening performance

Often at odds with others or picks fights

Noncompliant

Other Observations of Appearance or Behavior

General Observaations

Other issues reported or issues known to you (if a person appears ready to harm themselves or others, please immediately call 911 and report.)

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