Student of Concern Referral

This form is to refer: Non- emergency concerning behavior exhibited by a student of MSMC.

BEFORE YOU BEGIN: In an emergency or an imminent risk of a person harming themselves or others, immediately contact:

Local Law Enforcement by dialing 911, or
Campus Security and Safety at 845-569-3200

This referral is reviewed during normal business hours and may not be monitored after hours, on weekends, or during official College holidays. This form is NOT designed to report emergencies.

For assistance or consultation about your referral, please contact ACT at act@msmc.edu

Thank you for sharing your concerns for a student at Mount Saint Mary College. By reporting a student exhibiting concerning behavior or experiencing some form of distress, you are initiating supportive outreach to the student and helping to maintain Mount Saint Mary College as a safe campus environment.

Contact information:

Please provide your name and contact information to allow us to call or email if we have additional questions regarding your report. Anonymous reports are accepted but it may limit the College’s ability to address the concerns.

Your full name

Relation to student

Your office or cell

Date of incident/issue

Your email address

Specific Location

Involved Parties:

Student First Name

Student ID Number, if available

Student Last Name

Student Phone Number, if available

Role

Student Email, if available

Add another party

No data yet.

	#	Student First Name	Student Last Name	Role	Student ID Number, if available	Student Phone Number, if available	Student Email, if available

Incident Information:

Please select from the following options below that led you to be concerned about the individual(s) involved.

Please describe the behaviors and/ or circumstances that have prompted you to share your concerns. Please use as much detail as possible, including dates for any specific concerns and details about your interactions with the student.

Description

Have you addressed your concerns directly with the individual?

Yes No

If yes, please share how you have addressed your concern(s) and how the student reacted

Are you aware of any services the student is receiving that relate to your concerns?

Yes No

If yes, please specify

Is the student aware that this report is being submitted?

Yes No Unsure

Do you wish to remain anonymous if/when this student is contacted?

Yes No

if yes, the college will make every effort to maintain anonymity where possible

Submit