Jenzabar University

  *All reports are confidential and will only be shared on a “need to know” basis.

Tell us about yourself

First Name

Last Name

Email

Phone

Person of Concern

First Name

Last Name

Student ID#           (if available)

Course Code (Instructor Use Only)

Type of Concern

Please specify Other concern:

Description of concern

Has this behavior been observed in the past?

How would you rate the risk that this person will harm self and/or others?

Have you informed anyone else about this concern?

Please Specify