C.A.R.E.S. TEAM FORM - ONLINE FORMS

Location*

Please select the campus or location where the student of concern behavior is being observed.

Greeneville
Online

Acknowledgement*

I acknowledge that this form is not monitored 24/7 and should not be used in the case of an emergency or if there is a threat to safety and/or life. I acknowledge that in such instances, 911 or Tusculum University Campus Safety should be called.

Acknowledged

Student Information

Student Name*

Please enter the student's name

First Last

Student ID

Please enter the student's Tusculum ID Number, if you know it.

Student contact information: Sometimes your records my contain contact information for the student that we don't have on file. If you have the student's campus email or phone number for the student, please provide it below.

Phone

Campus Email

Referral Information

Please provide your information below.

Your Name

First Last

Referral Contact Information: Please provide your email address and/or phone number so that we can contact you if we have follow up questions.

Your Phone

Your Email

Your Role:*

Please select your role-type from the options list.

Other Role*

Please enter your role-type for this report.

Time and Location

Please enter the approximate date and time the situation occurred. If the situation is on-going, or you do not know a date, you may leave this field bank.

Time

:

Date

Description of the Situation

Required: Please provide as much detail as possible about your concerns. Describe what behavior, statements, observations, etc., have prompted you to make this referral and when applicable, please provide specific examples. The more information we have as a team, the better equipped we are to address the concern.

Description of your concern*

While not required, please list any steps your may have already taken (if any)

Description of steps taken

Upload Documents

Please feel free to attach any documentation related to this referral (e.g., screenshots, emails, photographs, or written work).

Drop files here or

Accepted file types: txt, jpg, jpeg, gif, png, xls, xlsx, doc, docx, Max. file size: 2 MB.

Report Verification

Verification