Revised 8/18/2014
Crisis Assessment, Intervention, and Response (CAIR)
This form is to be used for NON-EMERGENCY
situations only.
In the event of an emergency, please
contact Campus Police immediately at
562.860.2451 Ext. 2325, or call 911.
The purpose of this form is to identify initial
signs in students of noticeable distress before
they lead to deeper issues in their personal
and academic life. Please complete this
form and forward to the Dean of Student
Services in the Office Student Activities. You
may submit this form via e-mail at
CAIR@cerritos.edu
PLEASE NOTE: If you believe that a student
has violated the Student Code of Conduct,
please fill out the separate Student Conduct
Incident Report form instead.
For OSCG use only: Date rec’d:_______ Staff: _____
SCC: ___________________ CS ___ ST ___ ID ___
CIF ___ PR ___
Student First & Last Name:
___________________________________________
Student ID:
___________________________________________
Instructor/Staff Member Name:
___________________________________________
Cerritos College Email Address:
___________________________________________
Instructor/Staff Member
Preferred Contact Phone Number:
___________________________________________
Term (e.g. Fall 2014):
___________________________________________
Course (e.g. Math 115) & Section:
___________________________________________
Reason for Referral/Description of Concern
Please provide a detailed description of the situation, including dates and locations. You
may attach additional sheets, if necessary, and any related documentation:
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
CRISIS
INTERVENTION
FORM
