Care Team Reporting Form

Your Information

When reporting a student concern, please be aware that these reports are accessible to the student you are reporting, at the student's request. While anonymous reports are accepted, you are strongly encouraged to provide your name and contact information in order to allow the College to effectively address the concern you are reporting.

Your full name:

Your Role at WITCC:

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employee, learner, guest

Your phone number:

Your email address:

Email address must be of a valid format.

Nature of this report(Required):

This field is required.

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Type of concern

Supports Offered(Required):

This field is required.

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Please check the supports you have already referred the student to:

Date of incident(Required):

This field is required.

Time of incident:

Location of incident(Required):

This field is required.

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Campus Location

Involved Parties

Please be sure to add your own information and then add a new entry for each additional person involved.

Person Name or Organization

Select Role

ID Number

DOB (YYYY-MM-DD)

Phone number

Email address

Questions

Briefly describe the issue of concern for the student.(Required) This field is required.

Briefly describe any discussions you have had with the student regarding this concern, along with any referrals you have already made for assistance.(Required) This field is required.

Would you be comfortable visiting with a member of the WITCC Care Team in follow up to this reported concern?(Required) This field is required.

I understand that this request form is NOT to be used for emergencies requiring an immediate response, and this report will not be viewed outside of normal business hours, holidays, campus closure, etc. - and Care Team Response may take 3-5 days. For emergencies contact WITCC Campus Safety Office at (712) 274-6414(Required)

Yes No

You must make at least one selection.

Supporting Documentation

Photos, Video, email, Texts, and other supporting documents may be uploaded below. 5G Total capacity for the entire report. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

Email me a copy of this report

Your Information

Involved Parties

Questions

Supporting Documentation

Submission