Referral Form

IF THIS IS AN EMERGENCY DO NOT USE THIS FORM. INSTEAD, CALL 911.

Send a person of concern report by completing the items below.

Please note that certain professionals on the BTAT may be required to report or take other immediate action required by law based on the information submitted on the referral form.

* Denotes required information.

Background Information

Please provide the following information:

Your full name:
Your position/title:
Your phone number:
-
Your email address:
Nature of this report:*
Date of incident:*
Time of incident:
 : 
Location of incident:*
Specific location:

Person of concern

Please list the person of concern. Provide information in as many of the data fields as you can. Please start with identifying the person of concern and then add any others that may be involved or have relevant information. In the ID Number field please include the following information if known: for students - APID#; for faculty/staff -ZPID#; and for non-students - a Drivers License number.

Name:
Select gender:
Select role:
ID Number:
Date of birth:
Phone number:
-
E-mail address:

Additional person involved

Please list an additional person involved (excluding yourself). Provide information in as many of the data fields as you can. Please start with identifying the person of concern and then add any others that may be involved or have relevant information. In the ID Number field please include the following information if known: for students - APID#; for faculty/staff -ZPID#; and for non-students - a Drivers License number.

Other person's Name:
Other person's gender:
Other person's role:
Other person's ID Number:
Other person's date of birth:
Other person's phone number:
-
Other person's e-mail address:

Questions

In this referral to the Behavioral Threat Assessment Team, please select categories and provide related narratives that document what you factually know. It is important to avoid personal opinions, judgments, or inferences about the person or circumstances.

Please provide a detailed description of the incident/concern using specific, concise, objective language (Who, what, where, when, and how).*
Please indicate selections from the relevant category/categories which pertain to the person of concern in this report. Observations of Personal Appearance - Check all that apply:*
Please provide any details regarding the selected observations of appearance.
Please indicate selections from the relevant category/categories that pertain to the person of concern in this report. Physical Signs of Distress - Check all that apply.*
Please provide any details of physical signs of distress which cause concern.
Please indicate selections from the relevant category/categories that pertain to the person of concern in this report. Emotional Observations - Check all that apply.*
Please provide any details regarding emotional observations that cause concern.
Please indicate selections from the relevant category/categories that pertain to the person of concern in this report. General Observations- Check all that apply.*
Please provide any details regarding general observations that cause concern.
Please indicate selections from the relevant category/categories. Circumstances associated with the person of concern that have been reported or known to you personally. -Check all that apply.*
Provide any specifics or details regarding circumstances reported or known to you that cause concern.
Please provide any additional information of significance you wish to be considered in this referral.

Supporting Documentation

Photos, video, email, and other supporting documents may be attached below. Attachments may require some time to upload, please wait for confirmation. File may only be a jpg, jpeg, png, gif, doc, docx, xls, xlsx type file.

Choose a file to upload:

Final Step

Help us prevent spam reports by proving you are a human submitting this information. After completing the "CAPTCHA" you may submit the form.

Verification please: