Behavioral Intervention Team Reporting Form

Behavioral Intervention Team Reporting Form

Thank you for contributing to a safer USAHS by sharing your concerns about a member of our community. If you have questions or need further assistance, please contact a member of the BIT:

Candice Vasquez, Director of Student Welfare at cvasquez@usa.edu

Claudia Chahin, Asst. General Counsel at cchahin@usa.edu

Rudy Estrada, Director of Safety and Security at restrada@usa.edu

Please note:

This form is not intended to address emergency situations in which a member of the USAHS community may be in danger or pose a risk to themselves or someone else. In an emergency, you should take immediate action by calling 9-1-1 and/or directing the individual to the 24/7 mental health and safety resources below.

ComPsych Counseling Services- Free counseling services and resources available to all USAHS students, faculty and staff.

Call (844) 819-4777

National Suicide and Crisis Lifeline- Call 988 or (800) 273- TALK (8255)

When completing this form, it is important to provide as much information as possible so the BIT can properly respond and intervene. Requests to maintain the anonymity of a referral source will be honored to the degree possible but cannot be guaranteed since it may limit the ability of the BIT to investigate and respond. No person who, in good faith, reports threatening or otherwise troubling behavior will be subject to retaliation.

Referral Source

Please provide your information. The BIT may require additional information to follow up about your report.

Your Name*

Your Best Contact Phone Number*

Your Email*

Your Role*

Select or enter value

Your Campus*

Select or enter value

Student Information:

Student Name*

Student ID Number

Student Campus

Select or enter value

Student Program

Reason for Referral

Select or enter value

Date of Incident*

If multiple dates, please describe below.

Please list other parties who are aware of the situation or who have observed the behavior of concern.*

Please describe the event(s) including date(s), time(s), and all parties involved. Provide specific words or phrases used by the student if verbal and any interactions that could assist in a response. Describe tone of voice, facial expression, body stance, physical appearance, etc. You can also attach a separate document below.*

Please upload documentation related to the report such as text messages, emails, pictures etc.

Drag and drop files here or

Send me a copy of my responses

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