Southeastern Technical College Behavioral Intervention Concern Form Page 1
Behavioral Intervention Team
Full Name: ____________________________________________________________
Position Title (if applicable): _______________________________________________
Home Address:
City _____________________________ State ______________ Zip __________
Phone Number ________________________________________________________
Email Address ________________________________________________________
Nature of this report
Odd or Eccentric Behavior
Was a report filed with the Police
Concerning Behavior
Threatening Behavior
Self-Injurious Concern
Other, Please List
Date of Incident: ___________________ Time of Incident: _________________
Location of Incident:
Involved Parties:
Please list the individuals involved (excluding yourself)
Southeastern Technical College Behavioral Intervention Concern Form Page 2
Incident Description
Please provide a detailed description of the incident/concern using concise, objective language.
If the incident occurred in the classroom or as part of a course, please list the course name.
Provide as much detail as possible. (Use additional pages if needed).
Supporting Documentation
Please provide photos, videos, email, and other supporting documents.
* List here any supporting documentation you will be providing.
Submit your completed Concern Form using one of the methods below:
: (912) 538-3100 ATTN: Barry Dotson
Mail: Southeastern Technical College
ATTN: Barry Dotson
3001 East First Street
Vidalia, GA 30474
Southeastern Technical College is an Equal Opportunity Institution
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome