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Person of Concern Referral Form

You may also contact BART by telephone (312)-341-2323 or email: bart@roosevelt.edu

This form is for reporting emerging situations involving behavior that may impact the safety of the University community, but has not escalated into an emergency. Such situations involve disturbing or distressing behavior exhibited by faculty, staff, students or guests.

If this is an emergency, contact 911. If your concern is strictly a student conduct issue with no safety concern, contact the Student Conduct & Conflict Resolution office at ext.2016 or email osccr@roosevelt.edu.

Person of Concern Information

"Person of Concern" (POC) is the individual who has exhibited the disturbing or distressing behavior.

First and Last Name
*
(Optional - if any exists)
gender, height, weight, age, ethnicity, hair color, eye color, distinguishing marks or clothing
*
*
000-000-0000
Reporter Information

The 'REPORTER' is the person submitting this Person of Concern form. If there are others involved or have knowledge relating to your concern, please include them in the sections below labeled 'Others Involved and Witnesses to the Concerning Behavior'.

First and Last Name
*
*
000-000-0000
*
Is it OK to contact you?
In order for the BAT to fully address the situation, it may be more advantageous to be able to speak with you.
*
Best method to contact:


*
Incident Details
*
00:00 am/pm
*
i.e. building, floor, room number
*
Police Report


*
List all names - include email addresses and phone numbers, if known.
Please be as detailed as possible.
*
Type of Supporting Documents (if any)



*