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CARE Team Concern Reporting Form
IF YOUR CONCERN NEEDS TO BE ADDRESSED IMMEDIATELY AND CANNOT WAIT 48 HOURS, CALL 911 FOR MEDICAL / MENTAL HEALTH EMERGENCIES.
Contact information collected here will be used only if there are questions about your concern. Every effort will be made to keep the source of this information confidential.
YOUR INFORMATION
Your First Name:
Your Last Name:
Your Email:
Your Phone Number:
INFORMATION ABOUT THE STUDENT OF CONCERN
Student's First Name:
Student's Last Name:
Student's KSU Email (if known):
Student's Phone (if known):
Other Identifying Information:
Date of Observation of Incident
Time of Observation of Incident
Location of Observation or Incident
Please provide a brief description of the behaviors observed or incident you are reporting:
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