Southeastern Technical College Behavioral Intervention Concern Form Page 1
___________________________________________________
_______________________________
Behavioral Intervention Team
CONCERN FORM
Full Name: ____________________________________________________________
Position Title (if applicable): _______________________________________________
Home Address:
Street_______________________________________________________________
City _____________________________ State ______________ Zip __________
Phone Number ________________________________________________________
Email Address ________________________________________________________
Nature of this report
Odd or Eccentric Behavior
Was a report filed with the Police
Department:
Concerning Behavior
Threatening Behavior
Self-Injurious Concern
Yes
No
Unsure
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
Submit your completed Concern Form using one of the methods below:
Email: bdotson@southeasterntech.edu
Fax
: (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
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