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Reporter’s Contact Information
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Reporter’s Role (required) *
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Referral Information
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Does the student prefer to remain anonymous? (required) *
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If you don't know the full name of the student, Enter Unknown in the box (Example: John Unknown or Unknown Doe).
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Reason for Report/Referral (required) *
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Would you like to send a copy of this referral to University Police? (required) *
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Is the referral related to a specific incident? (e.g. suicide threat/attempt, sexual assault, stalking incident, classroom disruption, etc.) (required) *
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Date of Incident
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