Care Team Report
Office of Student Affairs
Your name: *
Name of person(s) completing this form. *If you choose to report anonymously, our follow-up on this report may be limited.
Your answer
Your email address:
Your answer
Your phone number:
Your answer
Date of Concern
MM
/
DD
/
YYYY
Time of Concern
Time
:
Person(s) of concern *
If unknown, put "unknown"
Your answer
Please identify how the person of concern is associated with HC?
Please supply any other known identifying physical description (if applicable)
Please do not use this to describe the situation.
Your answer
How can CARE Team best assist you?
Description *
Briefly describe your concerns (facts, dates, observations, etc.)
Your answer
Please check all that apply
What steps have you taken (if any) to address your concern?
Your answer
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