SCHENECTADY COUNTY COMMUNITY COLLEGE (SCCC)
Campus Assessment, Response, and Evaluation (CARE) TEAM REFERRAL FORM

(If you require assistance in completing this online form or if you require an alternate format, please email care@sunysccc.edu.)
 
Please complete this Referral Form if you have observed a student displaying disconcerting behaviors and/or potential threats of harm to self or others.  Your name and contact information are not required.  However, the CARE Team may be limited in their ability to respond if this information is not available.  If you are concerned of imminent danger, please immediately contact SCCC’s Security at 518-381-1308 and/or the police at 911.

I. Background Information

*required fields
1. Today's Date
  *  

2. Your first name
3. Your last name
4. Your position/title/role
5. Your phone number
6. Your email address
7.  What is the reason for this report?  Select all that apply. * 
8.  What is the location of the incident/observation? Indicate as many locations as appropriate.
  *  

9. Please indicate the date of the incident or when you began to notice specific behaviors of concern.
  *  

10. What was the approximate time of the incident/observation?
11.  Did you file an Incident Report about this situation with Security? * 
Yes
No
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