DO NOT report an emergency in this form. If this is an emergency call 9-1-1 and then call CCA Public Safety at 415.703.9510. If this is a psychological emergency, please contact CCA’s Mental Health Crisis Hotline at 510.594.5099.

After submitting the form, you will receive a confirmation email. This information will be reviewed within 3 business days. You can expect a delayed response during college closures.

Your Information:

Please provide the following information to ensure CCA can respond and follow up as appropriate.

Full Name

First, (Preferred), Last

Position/Title

CCA Email Address

Phone

Student Information:

To the best of your ability, provide the following information regarding person(s) involved.

Student Name

First, (Preferred), Last

Additional Names the Student Goes by

Student CCA ID #

As applicable (ID is either 7 or 8 digits)

Student email

Additional Person(s) involved

List additional person(s) involved if applicable. Include First, (Preferred), and Last Name(s) and any contact information available.

Concern Information:

Date

What was the approximate date/time when the concern began

Location

Summary of Concern

To the best of your ability, provide information regarding the concern, incident, or support need(s). Specific details are greatly appreciated, including duration of concern (if applicable.) Include specific behaviors and facts.

Action Already Taken

Have you or another person addressed the concern with the student? Please describe and include any referrals to campus resources already provided.

Level of Concern

Supporting Documentation

Please attach files here. You can upload up to three files. To upload more than three files, please add them to a single zip file before uploading. This form can not be used to upload video files. Please email video files to ccacares@cca.edu

This form is official communication with the college and is governed by the Family Educational Rights and Privacy Act (FERPA). By submitting this form, you acknowledge that the information provided is true to the best of your knowledge and will be viewed by the appropriate college officials and responded to accordingly.

I agree

Fields for form variables

Care Form - Staff & Faculty

Area of Concern:

Your Information:

Student Information:

Concern Information: