Incident Form

Behavior Intervention Team

Referral Form

Please provide detailed information regarding the observed behavior of concern or incident involving a WVSU student. In completing this form, you will be asked to provide your name and contact information. WVSU does not accept anonymous reports. Once the report is received, a designated staff member will investigate the incident and address the issue reported. Please be aware that you and the identified other person(s) may be contacted to provide further information and/or assistance. Action taken as a result of this report may be protected by federal privacy law (Family Education Rights and Privacy Act) and therefore becomes confidential information unless otherwise specified by the named student(s).

The incident report is ONLY to report WVSU student-related incidents. Questions regarding the submission of this form can be directed to Chris Jackson, Interim Assistant Vice President of Enrollment Management & Student Affairs by email at jacksoc@wvstateu.edu or by phone at (304) 204-4328.

Faculty or staff behavior that causes concern or apprehension, but is not an immediate threat or act of violence, must be reported to the Director of Human Resources for staff and to the Vice President of Academic Affairs for faculty.

These reports are received by the Behavior Intervention Team (BIT). Please describe the student behavior or change in behavior, that has prompted this report. Avoid using pronouns (he, she, etc.) to identify people. Indicate specific words, phrases and behaviors, including dates and times. If a subject used profanity, made threats, or spoke of harming him/herself, indicate specific words/phrases used. Include names(s) of campus personnel you contacted and actions taken, if any.

If in immediate danger, call 911 or contact West Virginia State University Campus Police at (304)-766-3353 or (304)-766-3181.

Background Information

Please provide detailed information regarding the incident you are reporting.

Your full name:
Your position/title:
Your phone number:
Your email address:
Your physical address:
Nature of the concern:
Date of incident:
Time of incident:
Location incident occurred:

Description/Narrative

Please provide a detailed description of the incident/concern using specific concise, objective language.

Witnesses of event (please be specific and include name and contact information if possible).

Name	Position	Address	Phone

Other people involved in the incident (please be specific and include name and contact information if possible).

Name	Position	Address	Phone	How were they involved?

You will receive an email indicating your report has been successfully submitted. Thank you.

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West Virginia State University (MyState)

Behavior Intervention Team