CARE Referral

Reporter Information

Please share your information with us so that we may follow up with you if we have questions or to thank you for reporting.

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Your full name:

Your University Affiliation:

Your phone number:

Your email address:

Email address must be of a valid format.

Person of Concern(Required):

This field is required.

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Primary Affiliation with KU

Urgency of Report(Required):

This field is required.

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If there is an immediate threat of harm to self or others, call 911 or 785-864-5900.

Date of incident(Required):

This field is required.

Time of incident:

Location of incident(Required):

This field is required.

Specific location:

For Whom Are You Concerned?

Please list the individuals involved. Complete as many of the listed fields as you are able.

If you have shared your information as the person submitting the report, you DO NOT need to include your information below.

Name or Organization

ID Number (if known)

Phone number

Email address

Hall/Address

Tell Us About Your Concerns:

Please describe the behaviors and circumstances that have prompted you to share your concerns. Use as much detail as possible, including dates. When possible, use exact quotes to describe any threats of harm to self or others. Describe the action steps you have taken up to this point to address your concern/support the individual. You will have opportunity to upload supporting documentation as well.(Required) This field is required.

Supporting Documentation

If you have emails, documents, screen captures, or photos you feel are relevant to this report, please upload them here. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

Reporter Information

For Whom Are You Concerned?

Tell Us About Your Concerns:

Supporting Documentation

Submission