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Online Early Alert Report
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Reporting Party Information
Your Name
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What is your role?
Student
Faculty
Staff
Other
Email Address
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Phone Number
Report Type
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Select
ONLY
ONE
.
Behavioral, Emotional or Mental Health
Students showing signs of of odd, inappropriate or altered behavior or mental health concerns
Basic Needs Referral
Students presenting barriers to academic success such as housing, transportation, financial issues, etc
Sexual Misconduct, Stalking or Intimate Partner Violence
Student of Concern Information
First and Last Name
Required
*
Please include full name and student ID if available. For academic issues, also include the CRN
Reason(s) for Report
What is the nature of the issue?
What is the nature of the issue?
Behavioral, Emotional or Mental Health issue
What is the nature of the issue?
Basic Needs Referral
What is the nature of the issue?
Sexual Misconduct Issue
Date/Time of Incident
January
February
March
April
May
June
July
August
September
October
November
December
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2019
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2028
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2030
2031
2032
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am
pm
Location of Incident
BEHAVIORAL, EMOTIONAL OR MENTAL HEALTH CONCERNS:
Please check all that apply
Severity
FYI
Serious Issue
Emotional Behaviors
Anxiousness
Emotional Outburst
Expressions of hopelessness, fear or worthlessness
Direct statements indicating distress
Suicidal remarks
Other
Physical behaviors
Change in energy levels
Change in hygiene or appearance
Suspected alcohol or drug use
Noticeable cuts, bruises, or burns
Socially withdrawn
Other
ACADEMIC PROGRESS
Please check all that apply
Attendance
Constantly Tardy
Consistently Leaves Class Early
Excessive Absences
Study Habits and Assignments
Continually submit substandard work
Does not turn in assignments regularly
May have difficulty understanding assignments
Student rarely or never participates in class
Learning Strategies
Lacks essential skills: reading, writing, math
Does not read assigned materials
Does not take notes
Does not perform well on tests
Does not organize well assignments
Retention Risk
Missed first 2 classes
Did not pass first test
Did not turn in first Assignment
Demonstrates likelihood to fail the class
ACADEMIC DEAN'S OFFICE
Type of Academic Issue
Type of Academic Issue
Grade Appeal
Type of Academic Issue
Academic Complaint
Type of Academic Issue
Plagiarism
Type of Academic Issue
Cheating
Type of Academic Issue
Other
Semester
Course
CRN
Instructor Name
BASIC NEEDS CONCERNS:
Please check all that apply
Basic Needs
Student reports issues with transportation
Student reports issues with childcare
Student reports financial issues
Student reports health issues
Student reports issues with housing
Student reports food insecurity issues
Student reports personal safety issues
Student reports issues with sufficient clothing
SEXUAL MISCONDUCT CONCERNS:
Please check all that apply
Category of Report/Disclosure
Sexual Harassment
Sexual Assault
Stalking
Intimate Partner violence (pertraining to spouse or live-in significant other)
Domestic Violence (pertaining to anyone living in the household - parent, child, etc.)
Dating Violence (pertaining to a dating relationship without living together)
Date of Report/Disclosure
January
February
March
April
May
June
July
August
September
October
November
December
01
02
03
04
05
06
07
08
09
10
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23
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27
28
29
30
31
2018
2019
2020
2021
2022
2023
2024
2025
What action is the reporter seeking?
Disclosure Only: Share information without a request for intervention.
Filing a Report: Investigation and action by College requested
Description
Please provide a detailed description of the issue(s) and your concerns.
Actions taken
Please describe any action you may have taken to address the concerning behavior and how the individual responded to your attempts.
Supporting Documentation
Please attach any supporting documents that would better assist the team in helping the person you are concerned about.
Confidentiality
Required
*
Please check the box to confirm you have read the confidentiality statement
*Confidentiality will be maintained as much as possible, however the college may be required to release some information in response to court orders or subpoena requests.