If you think this is an emergency, call 911!
For UCC Campus Security, call 541-440-7777
This form is not designed as an emergency response. Please be aware that this form will only be
read during normal business hours, Monday-Friday, 8:00 a.m. 4:30 pm.
If you have a security concern or safety concern please submit a report through security here:
If the student’s behavior needs to be addressed due to a Student Code of Conduct Violation
please complete the following form located: Student Conduct Incident Report Form
Student of Concern Referral
Umpqua Community College is committed to the health and safety of all members of our
community. To safeguard our community, UCC’s CARES (Care Assess Respond Evaluate Support)
team has developed a reporting system to share appropriate information so students can
receive or stay connected to the academic support and student wellness services they need.
This referral system is one element of a safe and supportive campus community.
What happens once this form is filled out?
Email this form to the Life Coach at if you would like the
student to be contacted quickly with potential campus and community resources –OR- if you
would like to submit the form to the CARES team.
Once this form has been submitted, the Life Coach or another CARES Team Member may
contact the reporting party for additional information prior to contacting the student. Once the
necessary information has been gathered, a staff member may reach out to the student (this is
determined on a case by case basis). During this contact, the situation will be assessed, students
may be offered services, are provided with appropriate resources and referrals, and may be
offered additional follow-up. Some referrals require additional attention. Based on the
student’s behaviors, those referrals will be discussed with the CARES Team, where additional
recommendations may be made.
Please Complete the Student of Concern Form on the Next Three Pages
What we need to know:
Student’s name: ___________________________________________________________
Identifying Information (student number/phone number): ____________________________
Your Name: ________________________________________________________________
Your Contact Information: ________________________
Describe the behavior that is concerning you:
Continue to Next Page
Prior acon you have taken: In some cases, prior acon may have been taken by a faculty or
sta member. Please check any of the following points that have been addressed with the
student. If statements have been delivered to the student in wring, please aach a copy to
this report.
A specic descripon of the behavior of the concern
A statement that the behavior of concern is disrupng the classroom environment
A statement that the behavior of concern must stop
A statement that further occurrences of the behavior of concern will result in the
removal by the instructor from the class session
I would like support and/or consultaon in communicang behavior of concern to the
None of the above
Not applicable
Level of concern: On a scale from 1 to 10 with 1 being of no concern and 10 being the highest
level of concern, indicate your level of concern
No concern Moderate concern Highest concern
1 2 3 4 5 6 7 8 9 10
How can the we best assist you?
No assistance needed, just an FYI
I would like advice on how to help this student
I would like someone to reach out to this student directly
It is okay to share that I made this student of concern referral with the student
Please keep referral source anonymous
I am not sure what help is needed
Thank you