University of Miami
University of Miami

Background Information

We highly encourage faculty, staff and students to provide their contact information.
Your name:
Your position/title:
Your phone number:
Your email address:
Your physical address:
Date of incident:
Time of incident: :  
Location of incident:
Specific location:

Student of Concern Information

His/Her First and Last Name
Please list any information about the student’s current residence. (e.g., Residential College, Off-Campus Address, etc.)

Incident Details

1. What is your relationship to this individual?
2. How long have you been aware of this concern?
3. How frequently, this semester, has the student exhibited the concerning behavior?
4. Have you addressed this concern with your fellow student?
5. Please list the clubs/organizations the student is involved in. (This information may be used to reach out to the student.)
6. Have you formally discussed this concern with any University faculty or staff?

Description / Narrative

Describe your concern in detail (Include nature of concern, description of behaviors, observable physical signs, events that have occurred and any other pertinent information)
Ex: Two weeks ago Stephanie told me she thinks she may have been assaulted while intoxicated at a party of campus. Since then she has not been getting out of bed on most days stating she does not feel well. Stephanie is usually always in class and very involved in several clubs and organizations on campus and has not been attending any meetings or going to class. She has made comments that the night of the incident was her fault and she wishes she was not here anymore. A few nights I have woken up to her crying. I have noticed cuts on her arms that I never noticed before. Her mother has also e-mailed me asking about Stephanie because Stephanie has not been returning her parents calls or texts. Stephanie also posted on Facebook that she is “tired and done.”



The ’Canes Care for ’Canes online report allows students to report concerns that they have about their fellow ’Canes while remaining anonymous if they choose.

Anyone providing false information may be subject to University disciplinary action and may be subject to legal action.

STOP: If this is an emergency or there is an immediate threat of harm to a student or the community dial 9-1-1, or call UMPD at 305-284-6666. DO NOT USE THIS SYSTEM! Submitted reports are responded to by the next business day.

 I agree with the above disclaimer and I understand that the form I am submitting is not for an emergency.