Student Incident & Care Referral Form

Is this an emergency?
Does the person you are creating a report for pose a potential threat of harm to self or others? If yes and an emergent or immediate threat is believed to exist, please call 911 first and then call Charleston Southern University Campus Security IMMEDIATELY at 843-553-5896 or text 843-371-8445. If no, please proceed with the report below.

Title IX Concerns
To notify the Title IX Coordinator of sex-based misconduct concerns, submit a Title IX Incident Report form here. Concerns may include: sexual harassment, sexual assault, dating/domestic violence, stalking, sexual coercion/exploitation, etc.

Please Note: The information submitted in this referral may be disclosed to appropriate University staff for evaluation and/or response, including but not limited to the Dean of Students Office, Charleston Southern University Security & Police Department, Student Health Services, Civil and Individual Rights (Title IX), Human Resources, Residential Living, Undergraduate Learning, Graduate School, Academic Success Center, Student Accessibility Services, and/or the student's academic advisor/college.

SELECT ONE

Student Conduct Incident Report

Student Care Referral

Your Information

Your Full Name

Your Email Address

Student You're Concerned About

NOTE: The information submitted in this referral may be disclosed to appropriate University staff for evaluation and/or response, including but not limited to the Dean of Students Office, the Security Office, Title IX, Human Resources, Residence Life, the Student Success Center, Student Accessibility Services, and/or the student's academic advisor/college.

Name of Student

Student's Email Address (if known)

Your relationship to this student

Tell Us About Your Concern

Tell us about your concern in an objective, factual, and concise manner. We ask that you avoid stereotypes, opinions, and labeling or diagnosing individuals. While not required, we strongly encourage you to talk with the student about your concerns and inform them you are making this referral.

Is the concern becoming worse?

Have you (or someone else) discussed these concerns with the student, and is the student aware of this referral?

May we share your name with the student as the person who submitted this referral?

Does the student have a trusting relationship with at least one person (e.g. friend, parent, instructor, advisor, coach, staff)?

Please share their contact information if available (Name, Phone, Email, and/or Address)

Does the person display concerning behaviors that you feel could pose a potential threat of harm to self or others?

Please acknowledge you are aware of the following: If an emergent or immediate threat is believed to exist, please call Charleston Southern University Police Department IMMEDIATELY at 843-553-5896 or text 843-371-8445. Immediate concerns should be addressed by public safety officials as soon as possible. Referral submissions are not monitored outside of standard business hours, on weekends, nor during university holidays or closures. Referral submissions will generally be reviewed within one business day of submission (to exclude after-hours, weekends, holidays, and closures).

I understand and confirm I do not believe this is an emergency.

If you have documentation regarding this referral, please upload it here:

Student You're Reporting

Name of Student(s) Involved

Student's Email Address (if known)

Your relationship to this student

Tell Us About the Incident

Does the person display concerning behaviors that you feel could pose a potential threat of harm to self or others?

Yes

If an emergent or immediate threat is believed to exist, please call campus security IMMEDIATELY at 843-553-5896 or text 843-371-8445.

Form submissions are not monitored outside of standard business hours, weekends, or holidays. Form submissions will generally be reviewed within one business day of submission (to exclude after hours, weekends, and holidays). Immediate concerns should be addressed by law enforcement as soon as possible by direct reporting to CSU security. If an immediate threat is not known, please provide as much detail and supporting documentation as possible within this form.

What is the nature of this incident?

Date of incident

Time of incident

Location of incident

Please describe the incident, including your involvement or how you became aware of the situation.

Are there any other people that either were present or can corroborate the information you are providing? Please provide their names and contact information (if available).

If you have documentation regarding this incident, please upload it here: