[]
1 Step 1
Early Alert Response System (EARS)

::::::: INDIVIDUAL YOU ARE CONCERNED ABOUT

Student's Nametrue
Student's ID Number (if applicable)students_id_number_if_applicable
Course Name (if applicable)course_name_if_applicable

::::::: CHECK ALL THAT APPLY FOR EACH SECTION

Emotional Well-beingwell_being_checkboxes
Academic Concernsacademic_checkboxes
Personal Concernsconcerns_checkboxes
Compliance Concernscompliance_checkboxes
Threatening Behaviorsthreatening_checkboxes
Disruptive Behaviorsdisruptive_checkboxes
Disturbed Behaviorsdisturbed_checkboxes

::::::: ADDITIONAL INFORMATION

Specific description of incident(s)specific_description_of_incidents
0 /
Please describe a specific incident or incidents involving the individual that relates to your concern. Information that is specific and concrete should be provided with as little editorializing as possible, stressing only the individual's concerning behavior. INCLUDE: Nature of the incident, specific behavior observed, dates, times, witnesses, impact of the behavior, and action taken (if any). DO NOT INCLUDE: Psychological jargon of any type, Diagonoses (e.g. "This person is a paranoid schizophrenic" or "This person is bipolar."), Speculation ("I think this person is on drugs"), Demeaning depictions (e.g. "She's crazy" or "He's not operating with a full deck.")
Other Behaviors not listed aboveother_behaviors
0 /
Have you discussed your concerns with the individual?true
Was the individual receptive?true
Explain other concerns if necessary, providing ONLY FACTS.other_information
0 /

::::::: MY PERSONAL INFORMATION

Namename
Job Titlejob_title
Phone number/extensionphone_extension

::::::: NOTICE

EVIDENCE TO SUGGEST FALSE OR MISLEADING REPORTS WITH INTENT TO DEFAME THE CHARACTER OF ANOTHER, MAY RESULT IN DISCIPLINARY ACTIONS.
Previous
Next