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Concerning Behavior Submission Form


IF YOU NEED TO REPORT AN EMERGENCY, CALL THE WICHITA STATE UNIVERSITY POLICE AT 316-978-3450, or DIAL 911.

To consult with a mental health provider after hours, call COMCARE Crisis Center at 316-660-7500.

Wichita State University cares about the health and safety of all members of our campus community. The purpose of the University’s Care Team (formerly UBIT) is to apply a multidisciplinary approach to preventing individuals from harming themselves or others, and generally to assist persons in need. These persons include members of the University community as well as community members who may pose a threat and or disruption to our campus community.

The Care Team accepts referrals and incident reports from any person who is concerned about the health or safety of a WSU student, employee, visitor, or the campus community at large. Once this form is submitted, members of the Care Team will review the information and take appropriate action, which may or may not include contacting you, the reported/referred person, and any others you have identified that may have relevant information or who may have been impacted by the reported/referred person. If you wish to make an anonymous report, the team will evaluate the report and determine what follow up (if any) is necessary to address the reported concerns.

Reporter Information

While anonymous reports are accepted, you are STRONGLY encouraged to provide your name and contact information in order to allow us to most effectively and efficiently address the concerning behavior. Each witness should complete his/her own copy of this report.

 
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Student, Faculty, Staff, Resident Assistant, Residence Life Coordinator, Community Member, Etc.
Email address must be of a valid format.
This field is required.
This field is required.
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Example: Room 200

Person of Concern, Witnesses, and Others Involved

Please list the individuals involved (excluding yourself), including as many of the listed fields as you can provide. We must have the name of the person you are concerned about in order to follow-up and provide appropriate assistance.

Involved party 1

Behavior/Incident Information

Please check all observed behaviors which are suggestive of a pathway of harm to self or others or are signs of distress.

Academic Concerns:
You must make at least one selection.
Physical Behavior Concerns:
You must make at least one selection.
Emotional Behavior Concerns:
You must make at least one selection.
Other Behavior Concerns or Signs of Distress:
You must make at least one selection.
Was your concern listed in the Academic, Physical Behavior, Emotional Behavior, or Other Behavior Concerns/Signs of Distress areas above?(Required)
This field is required.
This field is required.
This field is required.
Duration of Behavior(s):(Required)
This field is required.
Does the person of concern have a history of violence or self-harm?(Required)
This field is required.
This field is required.
Has this behavior/incident been reported to law enforcement?(Required)
This field is required.
This field is required.
Have you (reporter) notified the person of concern that you are making a referral to the Care Team?(Required)
This field is required.
How did you find out about Care team?(Required)
You must make at least one selection.
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.

Submission