Care Team Referral Form

Reporting Party — Your Information

Submitting an anonymous concern inhibits the college’s ability to fully investigate and assist students of concern. We ask you to complete all fields to the best of your knowledge.

First Name *

Last Name *

Phone *

Email (Hawkeye email preferred) *

Hawkeye ID #

I am a Hawkeye: *

• Faculty
• Staff
• Student

I'm typically at this location * - Select an option - Automation and Robotics Center Cedar Falls Center Main Campus Regional Transportation Training Center Van G. Miller Adult Learning Center

Incident Information

Date of incident or date when concerning behavior was first exhibited

Time of Incident

Location of Incident

• On Campus
• Off Campus

If On Campus, please provide the on campus location

Description of the incident and events leading up to it (who, what, where, when, why, how).

Students of Concern and Involved Parties

You can submit up to three students per form. If more students were involved, please submit another form.

Student 1: First Name

Student 1: Last Name

Student 1: Phone

Student 1: Email

Student 1: Hawkeye Student ID #

Student 1: If you don't know the above information about the student, what do you know about them? What identifying information can you provide? (Example: department of study, general physical description)

Student 1: Role

• Student of Concern
• Witness

Student 1: Is this student aware you are concerned about them?

• Yes
• No

Student 1: What's your relationship to this student? (Example: classmate, roommate, teammate, co-worker)

Student 1: Has there been any recent change in the student's behavior related to this incident, or prior to this incident? If so, please describe.

Student 1: Have you contacted anyone regarding this student? (Examples could include: other staff/faculty, an outside agency such as Riverview Center, local police or Hawkeye Public Safety). If so, please provide names if possible.

Student 1: Do you have any additional information about this student that may be helpful? If so, please describe.

Student 2: First Name

Student 2: Last Name

Student 2: Phone

Student 2: Email

Student 2: Hawkeye Student ID #

Student 2: If you don't know the above information about the student, what do you know about them? What identifying information can you provide? (Example: department of study, general physical description)

Student 2: Role

• Student of Concern
• Witness

Student 2: Is this student aware you are concerned about them?

• Yes
• No

Student 2: What's your relationship to this student? (Example: classmate, roommate, teammate, co-worker)

Student 2: Has there been any recent change in the student's behavior related to this incident, or prior to this incident? If so, please describe.

Student 2: Have you contacted anyone regarding this student? (Examples could include: other staff/faculty, an outside agency such as Riverview Center, local police or Hawkeye Public Safety). If so, please provide names if possible.

Student 2: Do you have any additional information about this student that may be helpful? If so, please describe.

Student 3: First Name

Student 3: Last Name

Student 3: Phone

Student 3: Email

Student 3: Hawkeye Student ID

Student 3: If you don't know the above information about the student, what do you know about them? What identifying information can you provide? (Example: department of study, general physical description)

Student 3: Role

• Student of Concern
• Witness

Student 3: Is this student aware you are concerned about them?

• Yes
• No

Student 3: What's your relationship to this student? (Example: classmate, roommate, teammate, co-worker)

Student 3: Has there been any recent change in the student's behavior related to this incident, or prior to this incident? If so, please describe.

Student 3: Have you contacted anyone regarding this student? (Examples could include: other staff/faculty, an outside agency such as Riverview Center, local police or Hawkeye Public Safety). If so, please provide names if possible.

Student 3: Do you have any additional information about this student that may be helpful? If so, please describe.