Report of Actual or Potential Self-Harm

As a student, staff, or faculty member, you may become aware of a student experiencing suicide ideation or self-harm.  Our community has a responsibility to help students in distress.  Please complete this form if you are concerned about a student, and a small group of student affairs staff will follow up with that person to provide support.

Student Affairs Report of Actual or Potential Self-Harm

Student Affairs Report of Actual or Potential Self-Harm

  • STUDENT INFORMATION

    Please record all the information you know about the student for whom you have concern.




  • INCIDENT INFORMATION

  • Date Date / /
    Pick a date.
  • Time Time :



  • To the best of your knowledge did this incident or concern involve...

  • DELIBERATE SELF-HARMING (non-suicidal)
    DELIBERATE SELF-HARMING (non-suicidal)
  • SUICIDE RISK
    SUICIDE RISK



  • Briefly describe the events leading up to and surrounding the incident.

  • Was the student informed that a report would be made and the student should anticipate contact from the Dean of Students’ Office?
    Was the student informed that a report would be made and the student should anticipate contact from the Dean of Students’ Office?



  • REPORTER INFORMATION