CARE Team Reporting Form

This form is for the use of students, faculty, or staff of Mesalands Community College. Please provide detailed information regarding the behavior of concern you are reporting. You are not required to complete the entire form in order for the report to be submitted. Although anonymous reports are permitted, doing so may limit the College’s ability to investigate and respond to a report. Once the form is received, a member of the CARE Team at the College will review the information and take appropriate action.

Making this report to the Mesalands Community College’s CARE Team should never take the place of dialing 911 if a person feels threatened or that one’s safety or the safety of others is at risk.

Your Full Name
Your Phone Number
Email Address
Date of Incident
Time of Incident
Location of Incident
Specific Location (include Apartment number)

Party #1
   Name or Organization
   Role
   Mesalands ID Number
   Date of Birth
   Phone or Email

Party #2
   Name or Organization
   Role
   Mesalands ID Number
   Date of Birth
   Phone or Email

Party #3
   Name or Organization
   Role
   Mesalands ID Number
   Date of Birth
   Phone or Email

Please indicate any relevant category/categories that pertain to this CARE Team incident report: (Required)

Please provide a detailed description of the incident/concern using specific concise, objective language (Who, what, where, when, why, and how). (Required)

Photos, video, email, and other supporting documents may be attached below. 4MB maximum total size. For larger files please include share links from cloud services such as Dropbox, Google Drive, Microsoft One Drive or YouTube in the URL field below.

Large file or relevant URL

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