Tobacco-Free Incident Referral Form—to be forwarded to Student Health Services
Person Being Referred: ______________________________________________________
First Name (if known) Last Name (if known)
Status: Student
Faculty
Staff
Visitor
Gender: Male
Female
General description of the individual: __________________________________________
Person Making the Referral: __________________________________________________
First Name Last Name
Phone: ______________________ Email: __________________________
Date of Incident: ________________________________________________________
Day of Week Month Day Year
Occurred/Behavior Observed: TIME _______ AM
PM
Location of Incident:
Have you advised the person of this referral? YES
NO
If no, please explain:
Description of the Incident:
Please provide a detailed description of the incident/observed behaviors. Include the name of witnesses and their
contact information, if available. Be specific; record behaviors, not assumptions.
______________
Date
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