Campus Assessment, Response and Evaluation (CARE) Team Referral Form

You can make a referral to the CARE team in two ways: contact the chair of the CARE Team at 402-872-2246 or complete the form below which will be sent directly to the chair of the CARE Team. If there is an imminent threat to anyone’s personal safety of if there is an emergency in progress, please contact Campus Security at 402-872-2411 or local emergency services at 911.

When making a referral in writing or by phone, please provide a detailed description of the situation that is causing you to be concerned, using language as specific, concise, and objective as possible. Please forward any documentation you wish to be a part of the review to the chair of the CARE Team, Student Center Building and/or any electronic/supporting documentation to mthielen@peru.edu.

Please indicate your affiliation with Peru State College *
Did you personally witness the situation or behavior?
Please list the individual(s) name(s) you are concerned about (or description of individuals if name is unknown):
Describe the situation or concerning behavior below as clearly as possible:
(If possible, please include: Date and time, location and other witnesses)
Follow-up Information:

If you are submitting a report and wish someone to follow-up with you, please provide your contact information below. The information will be directed to the appropriate area and someone will respond to you regarding this report. If no information is provided, the report data will be used for informational purposes only.

Please note: CARE Team Referrals will be reviewed by the Associate Vice President for Student Affairs Monday through Friday between the hours of 8 a.m. and 5 p.m.

Reports submitted after hours will be reviewed promptly on the next workday following the submission of the report.
I would like someone from the appropriate office to contact me regarding this referral. *

I would like someone from the appropriate office to contact me regarding this referral. Yes No
Your Name Your Name First Last
Phone Phone - ### - ### ####
Email
Truth in Disclosure Statement

By submitting this form, I hereby certify that the information I have provided in this report is true, correct, and complete to the best of my knowledge.
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What is "one" as a number?

Campus Assessment, Response and Evaluation (CARE) Team Referral Form

Campus Assessment, Response and Evaluation (CARE) Team Referral Form

Follow-up Information:

Truth in Disclosure Statement