Report Distressed Individual

Health and Safety Referral Form

If you are concerned about the health, well being, or safety of a CSU student or CSU employee, you are encouraged to complete this form. Examples of why you may want to complete and forward the form include but are not limited to:

Threats, gestures, writings or attempts related to suicide or violence
Harmful to themselves or others
Self-injurious behavior (e.g. cutting self)
Alcohol or other substance abuse problems
Pattern of bizarre behaviors or actions
Hospitalization for mental health issues or drug or alcohol use
Sudden, rapid weight loss or gain
Poor health due to restrictive eating or concern this person has an eating disorder
Disruption to the living, learning or working environment

This is not a complete list. Please complete the form or call (970) 491-1350 if you have any reason to be concerned about a CSU community member’s health or safety.

DO NOT USE this referral form for any immediate crisis or emergency. Referrals will only be reviewed during normal business hours and may not be immediately reviewed. In the event of an emergency, call 911 or CSU Police at (970) 491-6425.

This form is designed to help the individual you are concerned about, not to punish them.

All reports will be treated with discretion and will be treated with a reasonable expectation of confidentiality. Information from this form may be shared with appropriate individuals in order to help protect the safety and health of those involved in any incidents reported.

You may remain anonymous when reporting through this form. However, it is very helpful to the university to have your contact information and name if there is a need to obtain more information about the situation or clarify information. In addition, without adequate information, the university may not be able to help. Therefore your contact information is strongly encouraged. Regardless, of whether you submit your name and contact information, every attempt will be made to review and address the concerns you submit on this form.

Information about the distressed individual
Full name of the person or people you are concerned about
CSUID of the person you are concerned about, if known
The person of concern’s date of birth or approximate age
The person of concern’s local address, department or office address, major, hometown, or high school if known (these identifiers are helpful when there are multiple persons with the same or similar name)
Person of concern’s phone - (###) - ### ####
Person of concern’s email address
Information about the incident(s)
In the following boxes, please submit as much detail as possible about the incident or incidents that have caused you to be concerned about this person’s wellbeing or the wellbeing of others.
Date of incident / MM / DD YYYY
Time of incident : HH : MM AM/PM
Location of incident or incidents
The nature of the incident (e.g. unusual behavior, extreme agitation, etc?)
What did you observe to take place or what was reported to you?
If the incident was reported to you, what is the name of the individual who told you about it, and what is their relationship with the person of concern?
If there were any threats of harm to others or self, please describe.
DO NOT USE this referral form for any immediate crisis or emergency - if this person has threatened to hurt themselves or others, immediately call 911 or CSU Police at (970) 491-6425.

Was the incident resolved and, if so, what was the resolution of the incident (e.g., stabilized by friends or called police)? If not, have there been any additional developments we should be aware of?
If police were involved what police agency responded?
If you have a police report on the incident, what is the police report number?
Do you know if this person has been involved in previous incidents? Or of any sanctions, interventions, or involvement the individual has had with services either on or off campus?
Is there anything else we should know about?
Information about the person making this report
Your Name
Your Phone - (###) - ### ####
Your Email address
Your relationship to individual
What is your affiliation with CSU? (student, employee, instructor, professor, neighbor, etc.)
Have you discussed this referral with the individual? Yes No
Would you like confirmation that your report has been received? Yes No
DO NOT USE this referral form for any immediate crisis or emergency. Referrals will only be reviewed during normal business hours. In the event of an emergency, call 911 or CSU Police at (970) 491-6425.

Colorado State University

the Department of Public Safety

Health and Safety Referral Form

Information about the distressed individual

Information about the incident(s)

Information about the person making this report

Safety at CSU

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