Concerning Behavior Report

Response Information

Your full name:

Your phone number:

Your email address:

Email address must be of a valid format.

Primary Behavior of Concern(Required):

This field is required.

Date of incident(Required):

This field is required.

Learn more

If more than one date, please use today's date and provide detail using the text box below

Time of incident:

Location of incident(Required):

This field is required.

Learn more

If more than one location, choose the most recent and provide detail using the text box below.

Specific location:

Individual of Concern AND Affected Individuals

Please list the person of concern's information as well as other individuals involved (including witnesses), including as many of the listed fields as you can provide. If you have listed your information as the person submitting the report, you DO NOT need to include your information below.

Name or Organization

Select Role

Student ID or Employee ID [if known]

DOB (YYYY-MM-DD) [if known]

Phone number [if known]

UNCG Email [if known]

Tell Us About Your Concerns

Please provide as much information as possible including, but not limited to, dates, communications, descriptions, timelines, etc.

Please describe ALL behaviors of concern:(Required) This field is required.

Please list any other University departments or outside agencies that were contacted about the concerns you have shared: This field is required.

Please indicate if any of the following actions were taken as a result of the described concerns:

Arrest Contact with individual of concern's family or support network Emergency Medical Services called - individual transported Emergency Medical Services called - transport refused Emergency Medical Services called - no transport needed Voluntary Commitment (Mental Health) Involuntary Commitment (Mental Health)

You must make at least one selection.

Supporting Documentation

Photos, video, email, and other supporting documents may be attached below. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

Email me a copy of this report

Response Information

Individual of Concern AND Affected Individuals

Tell Us About Your Concerns

Supporting Documentation

Submission