IF YOU THINK THIS IS AN EMERGENCY, CALL 911! FOR THE SECURITY DESK CALL 336-713-1568 This form is not designed as an emergency response. Please be aware that this form will only be read during normal business hours, Monday-Friday, 8:00am-5:00pm. Student of Concern Program WFSM is committed to the health and safety of all members of our community. To safeguard our community, WFSM’s CARE Team has developed a comprehensive reporting system to share appropriate information so students can receive or stay connected to the academic support and student wellness services they need. This reporting system is one element of a safe and supportive campus community. Who Should Use This Form? This referral form is for the use of all members of the WFSM community, including student, faculty, and staff. We encourage the friends and family members of students in distress to utilize this form as well, to share any pertinent information in support of our students. Any questions regarding completing this form should be directed to CAREteam@wakehealth.edu. What Happens Once This Form is Filled Out? Once this form has been submitted, the Case Manager may contact the reporting party for additional information prior to contacting the student. Once the necessary information has been gathered, a staff member may reach out to the student (this is determined on a case by case basis). During our meetings, students are provided with appropriate resources and referrals and are offered additional follow-up. Some referrals require additional attention. Based on the student's behaviors, those referrals will be discussed with the CARE Team and additional recommendations may be made. Reporter Information Your Full NameYour Relationship to the StudentYour Phone NumberYour Email AddressDate of Incident (required) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 January February March April May June July August September October November December 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 Time of IncidentLocation of Incident (required) Involved Parties Please list the names of the student of concern as well as any witnesses to the behavior or incident you are concerned with. NameRole Student of Concern Witness Phone Number (if known)Email (if known) Details of Behavior / Incident Please provide a detailed description of the incident using specific, concise, objective language. Include the details of the incident(s) and the behaviors observed. Focus on the Who, What, Why, Where, When, and How. Indicate specific words, phrases, and interactions. If you have listed an individual as an involved person, he/she/they should appear at least once in the narrative. Additionally, please explain any initial actions you or someone else may have taken in response to this incident. Details
