Report a Concern Form In the event of an emergency, please dial 911. Complete this form after reporting the emergency.Your Contact InformationYour Full Name First Last What is your role at Calbright?Faculty, Staff, Student, Community MemberYour Email* Please use your Calbright College email address if submitting as a student or a staff member.Your Phone NumberYour Student ID (CCCID)Nature of this report*Please Choose...Academic GrievanceAmericans with Disabilities Act (ADA)/504/508 ViolationDiscrimination/Hate Crime (see description below)Disruptive BehaviorPersonal WellnessDating/Domestic Violence, Sexual Harassment/Assault, StalkingThreatening/Violent Behavior (Written/Verbal)Website AccessibilityOtherThreat to self or others*Please Choose...NoYesDo you perceive this person to be a potential threat to self or others?Date of incident* MM slash DD slash YYYY Student or Employee?*Please Choose...I am reporting an incident involving a student.I am reporting an incident involving a staff or faculty member.N/ABackground InformationPlease provide a detailed description of the incident/concern focusing on facts, including people involved (who, what, where, when, why, and how).*Do you wish to remain anonymous?* No YesPlease detail any action(s) that you have taken in response to this incident. If no action was taken, then type "none" in the text box below.*CONCERNING BEHAVIOR There are NO concerning behaviors Aggressive Behavior Bizarre/Disjointed Thoughts Concerning Eating Behaviors Dating/Domestic Violence Depression or Extreme Sadness Disturbing Writing or Discussion Disheveled Appearance Excessive Anxiety Extreme Mood Swings Emotional Outbursts Homelessness Loner/few or no close friends Missing after attempts to contact Obsessively Suspicious/Paranoid Physical Self-harm Seeing/Hearing Things Significant Change in Appearance/Behaviors Substance Abuse Suicidal Remarks or Attempts Talking to Self Threats (Direct or Veiled) Unusual Bruises, Cuts, or Abrasions Withdrawal from Social Groups Other (Specify in narrative)Check all that applyIf this claim is about discrimination or a hate crime, please select one or more of the following actual, perceived or associated protected classes: Age Ancestry Color Ethnicity Gender Gender Expression Gender Identity Genetic Information Marital Status Medical Condition Military and Veteran Status National Origin Physical or Mental Disability Pregnancy Race Religion Sexual OrientationAcknowledgment and Submission* I acknowledge that the information I provided in this report is accurate and truthful to the best of my knowledge.Supporting DocumentationPhotos, video, email, and other supporting documents may be attached below. 20MB file size limit. Drop files here or Select filesAccepted file types: jpg, png, pdf, Max. file size: 20 MB.Attachments require time to upload, so please be patient after submitting this form.CAPTCHANameThis field is for validation purposes and should be left unchanged.