Two female students listening in class
Magnolia Avenue students talking on campus
Male nursing student listening in class

Behavioral Intervention Team - Referral Form

The BIT responds to reports of disruptive, problematic or concerning behavior or misconduct, conducts an investigation, performs a threat assessment, and determines the best mechanisms for support, intervention, warning/notification and response. The team then deploys its resources and resources of the community and coordinates follow-up. The team also identifies patterns of concerns for a student or group of students across all campuses.

In the event of an emergency or imminent danger, always contact campus security or dial law enforcement at 9-911.

Date:

Campus:
Hardin Valley Blount County Division Street Magnolia Avenue Strawberry Plains


Reporting Contact Info

Reporting Person’s Name:

Email:

Additional contact info:

Classification:
Faculty Staff Student

Other (please explain):


Referred Person's Information

Full Name of Referred Person:

Gender:

Phone:

Classification:
Faculty Staff Student

Other(please explain):


The Issue

How did you become aware of this concern? Did you observe it yourself, or did someone else tell you about it:

Concerns or reason for referral – check all that apply
Extreme verbal or written harassment or threats
Extremes, or changes in, appearance such as looking disheveled, disoriented, extreme low energy or apathetic
Disturbing writings or talking about – suicide, violence in their past or future, obsessions with harming or violence
Signs of paranoia or making references that are not germane to the topic or not related to the situational context
Under the influence of drugs/alcohol
Person self-disclosed
Other(please explain):

Incident Date:

Provide a description of the incident or behavior of concern. Please provide details in chronological order and include your observations of specific behavior, statements made and location:

What action, if any, did you take?

Witnesses (please use full names, contact information, or P# if possible):