*Campus Police Referral/Intervention Form

* = required field

Some content may be updated based on selection

Referral/Intervention Form

Read the statement below before completing this form. Select "I understand" to verify you have read and understand the statement.

STATEMENT: Use this form to submit a Referral or Intervention Request on Suspicious Behavior/Persons on Campus. IF THIS IS ON-CAMPUS EMERGENCY, DO NOT USE THIS FORM. CALL: 205-925-3587 (Birmingham Campus) or 205-426-3654 (Bessemer Campus). IF THIS IS AN OFF-CAMPUS EMERGENCY, CALL 911. IMPORTANT DISCLOSURE: Intentionally submitting a false report police may subject you to investigation or criminality.

I UNDERSTAND

Your First Name:

Your Last Name:

Your Email:

Your Phone #:

Your Full Street Address:

Apartment Number, if applicable:

City:

State/Province/Region:

Zip Code:

Country:

Your relationship to the person of CONCERN:

First Name of the Person of CONCERN. If you do not know, state: " I DO NOT KNOW":

Last Name of the Person of CONCERN. If you do not know, state: "I DO NOT KNOW" :

Does the Person of CONCERN have a Nickname. If so, what it is? If you do not know, state: "I DO NOT KNOW":

Gender of the Person of CONCERN:

Male

Female

Unknown

Approximate age of the Person of CONCERN:

What is Your concern related to this individual?

What are the circumstances associated with the person of concern that have been reported or known to you personally?

Are there other concerns NOT listed (please provide specifics):

If the person is taking a class with you, provide us with more details. What CLASS are you TAKING TOGETHER? Example: ENG101, MTH111, etc...

If you have the course CRN, what is it? Example: 04563

What Campus?

What Building?

What room number?

What time does this class meet?

What days does the class meet?

Please wait for files to finish uploading