Student Care Report Form

Background Information

Faculty, staff, students, and families are encouraged to share concerns about the well-being of a student with the Student Care Team to provide a more complete profile of the student of concern. The Student Care Team responds to students (and their families, faculty, and staff) when concerns for a student's health, welfare, and safety are identified. Phone calls to the Dean of Students Office are still welcomed and encouraged. As always, emergency situations should be immediately directed to the University of Louisville Police Department at (502) 852-6111 or 911.

Your full name:

Your position:

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:

Student of Concern

Name

ID Number

Involved Student Information

Student Concern(s) and/or Observed Behavior(s) Please describe the concern(s)/observed behavior(s) you are reporting.(Required) This field is required.

Please share what support has been provided thus far and any related services the individual is currently receiving, if known:(Required) This field is required.

How can the Student Care Team best assist you?(Required)

No assistance needed (submitting information as an FYI) I would like advice on how to help this individual I would like someone to reach out to this individual I am not sure what help is needed

You must make at least one selection.

Is the student aware a report of concern is being submitted on their behalf?(Required)

Yes No Unsure

You must make at least one selection.

Do you wish to remain anonymous if/when the student is contacted? **If it is your preference to remain anonymous, staff will make every effort to maintain your anonymity. However, please know anonymity can never be guaranteed. Also, we or other University officials may need to follow up with you to gather additional information to help us most effectively support the student.(Required)

No Yes

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.

Background Information

Student of Concern

Involved Student Information

Supporting Documentation

Submission