Your Information:

Please provide the following information to ensure CCA can respond and follow up as appropriate. You may choose to submit this form anonymously, however if you choose not to include your name and contact information, there may be limits to the College's ability to adequately investigate or address the situation, or both.

Full Name

First, (Preferred), Last

Email Address

Phone

Information about the Person You are Concerned About:

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

Name of the person the concern is about

First, (Preferred), Last. If submitting on your own behalf, list "Self."

Additional Names they may go by

CCA ID #

As applicable (ID is either 7 or 8 digits)

Email address

Phone Number

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. If you are reporting anonymously the level of detail provided is crucial for CCA to try and follow up so please provide as detailed as possible account of your concerns.

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 - Student

Area of Concern:

Your Information:

Information about the Person You are Concerned About:

Concern Information: