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Concerned Person Information

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Your full name:

Your role/title:

Your phone number:

Your email address:

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Your Department:

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If you are a Stanford faculty/staff, please share the full name of the unit where you work.

Nature of this report(Required):

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Please choose an option that describes the most significant concern you are sharing.

Level of Concern(Required):

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Please choose an option that describes your level of concern about this referral.

Date of incident(Required):

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Time of incident:

Location of incident(Required):

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Specific location:

Student(s) of Concern

Student Name

SUID Number

Email address

Description of event

Involved Parties: Please list any involved parties, as well as their SUID numbers and/or other contact information. You do not need to repeat information already provided above under "Students of Concern".

Description/Narrative: WHO, WHAT, WHEN, WHERE, WHY, and/or HOW: Please describe in as much detail as possible the specific concern or incident that occurred. When using pronouns, be clear about who you are referring to. Indicate specific words, phrases, interactions, and behavior. Give dates and times. If a person used profanity, made threats, or spoke of harming themself, indicate specific words/phrases used. If a student was loud or disruptive, indicate behaviors associated with the disruption, and describe any injury or damage to person(s) or property. If this is a student behavioral or emotional concern, please describe the student's behavior that has prompted this referral.

Action(s) Taken: Please describe any actions that were taken to follow up on this concern, including name(s) of campus personnel or other departments you contacted.

Involved Parties (if different from above): This field is required.

Description/Narrative:(Required) This field is required.

Action(s) Taken:(Required) This field is required.

Supporting Documentation

If your attachment size exceeds 5GB, please contact the Dean of Student's Office (deanofstudents@stanford.edu) to make arrangements for submission. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

Notify Additional Staff or Departments

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Dean of Students - Student of Concern Form

Concerned Person Information

Student(s) of Concern

Description of event

Supporting Documentation

Notify Additional Staff or Departments

Submission