Student of Concern Report

Reporter Information

Enable additional features by logging in.

Your full name:

Relationship to the concerned:

Your phone number:

Your email address:

Email address must be of a valid format.

Date of incident(Required):

This field is required.

Time of incident:

Location of incident(Required):

This field is required.

Specific location:

Involved Parties

Provide as much information as possible to ensure proper identification of the individual.

Full Name (First Last)

Role

PUID Number

Phone number

Email address

Address

Specific Information

Please be as detailed as possible in answering the following questions. You will also have the opportunity to upload any supporting documents at the end.

Please note that this report is not intended to initiate a conduct process. It is solely focused on responding to concerning behavior and providing help.

The student attends classes with Purdue:(Required) This field is required.

Describe the student's behaviors that are currently a cause for concern.(Required) This field is required.

How long has the above behavior been going on?(Required) This field is required.

When was your last communication with the student?(Required) This field is required.

What is the history of the above concerns and/or are there other individuals who have reported these concerns (peers, staff, etc.)? This field is required.

Are you aware of any previous interventions that have been made for the individual and the result of those interventions? This field is required.

How would you prefer that a staff member from the Office of the Dean of Students follow up with you?(Required)

No follow up Follow up by phone Follow up by e-mail Follow up in person by meeting with a staff member from ODOS

This field is required.

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.

Reporter Information

Involved Parties

Specific Information

Supporting Documentation

Submission