CARE Team Reporting Form

Background Information

(Please leave contact information blank if you would like to remain anonymous; keep in mind that anonymous reporting may limit the ability of the CARE Team to fully investigate the concern.)

Your full name:

Your position/title:

Your phone number:

Your email address:

Email address must be of a valid format.

Date of incident(Required):

This field is required.

Time of incident:

Location of incident(Required):

This field is required.

Specific location:

Involved Parties

Please provide information regarding the person of concern and any other witnesses to the concerning behavior.

Name

Role

T Number

DOB (YYYY-MM-DD)

Phone number

Email address

Hall/Address

Incident Information

In the space below, please provide a description of your concern. The narrative should be as detailed as possible. This field is required.

Supporting Documentation

You may also provide supporting documentation in person to Amy Pennington, AVP/Dean of Students and Title IX Coordinator and CARE Team Chair, Doc Bryan Student Services Center, Suite 233, 1605 Coliseum Drive, Russellville, AR 72801. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

Background Information

Involved Parties

Incident Information

Supporting Documentation

Submission