Student/Employee Concern Report The Behavioral Intervention Team (BIT) responds to non-immediate concerns and takes a proactive approach to discuss potential issues, intervene early, and provide support and behavioral response to students displaying varying levels of disruptive, disturbed, and/or distressed behaviors before they rise to the level of a crisis. Name* First Last Date* Date Format: MM slash DD slash YYYY What is your role at College of Alameda?*Select OneStudentFacultyProfessional StaffAdministratorEmail Address*Phone Number*Student ID (if you do not have one leave blank)Nature of this report*Select OneAcademic GrievanceAmerican with Disabilities Act (ADA)/Section 508 ViolationDiscrimnation/HateDisruptive BehaviorTitle IXThreatening/Violent Behavior (Written/Verbal)Web AccessibilityOtherThreat to self or others*Threat to selfThreat to othersDate of Incident* Date Format: MM slash DD slash YYYY Student or Employee*Select OneStudentEmployeePlease provide a detailed description of the incident/concern focusing on fact, including people involved (who, what, when, where, why, and how).*Do you want to remain anonymous?*YesNoPlease detail any action(s) that you have taken in response to this incident. If no action was taken, then type "none" in the text box below.*Concerning Behavior (Select all that apply)*There are NO concerning behaviorsConcerning Eating BehaviorsDisturbing Writing or DiscussionExtreme Mood SwingsLoner/few or no close friendsPhysical Self HarmThreats (Direct or Veiled)Agressive BehaviorDating/Domestic ViolenceDisheveled AppearanceEmotional OutburstsMissing after attempts to contactSeeing/Hearing ThingsSuicidal Remarks/AttemptsUnusual Bruises, Cuts, or AbraisionsBizarre/Disjointed ThoughtsDepression or Extreme SadnessExcessive AnxietyHomelessnessObsessively Suspicious/ParanoidSignificant Change in Appearance/BehaviorsTalking to SelfWithdrawal from Social GroupsIf this claim is about discrimination or a hate crime, please select one or more of the following actual, perceived, or associated protected classes.*AgeEthnicityGender IdentityMedical ConditionPhysical or Mental DisabilityReligonAncestryGenderGenetic InformationMilitary and Veteran StatusPregnancySexual OrientationColorGender ExpressionMarital StatusNational OriginRacePlease submit any supporting documents (email, photos, videos, etc). Drop files here or Acknowledgment and Submission* I acknowledge that the information i provided in this report is accurate and truthful to the best of my knowledge.
