PIERCE Behavior Intervention Referral Form Use this form to report any non-urgent student behaviors only. If the behavior threatens the personal safety of students, faculty or staff, or is displayed with such emotional intensity that it engenders fear or concern in others, immediately contact the Sheriff’s Office at (818) 710-4311 or call extension 4311 from any campus phone. Student Last name: name: Student ID No: Indicate your perceived level of risk: Mild Risk Moderate Risk Elevated Risk Non-urgent, informational only MILD RISK: Disruptive or concerning behavior. Student may or may not show signs of distress, No threat made or present. MODERATE RISK: More involved or repeated disruption, Behavior more concerning, Likely distressed or low-level disturbance, Possible threat made or present, Threat is vague and indirect, Information about threat or threat itself is inconsistent, implausible or lacks detail, Threat lacks realism, Content of threat suggests student is unlikely to carry it out. ELEVATED RISK: Seriously disruptive incident(s), Suspected substance abuse, Bizarre or unusual behavior indicating distress. Call Sheriff’s Office immediately. SEVERE RISK: Threat of harm to themselves or others: Call Sheriff’s Office immediately. Date(s) behavior was observed: Reason for referral: 1. Describe in clear and specific details the observed behavior(s). Do not make inferences, state only the facts. State specific words or phrases used and interactions. Describe tone of voice, facial expression, body stance, physical appearance, etc. 2. Your recommended action: For example, is this referral for information only? Do you think counseling is indicated? Disciplinary action? Any other thoughts? Please include your concerns and any conclusions you have drawn. 3. Please list other persons who may have witnessed the reported behavior: 4 Has the observed behavior been discussed with the student? (please explain) 5. Pierce Faculty/Staff making the referral: Name Title Office Phone: Cell: Email: To submit please save this document on your hard then email it to
PIERCE Behavior Intervention Referral Form Use this form to report any non-urgent student behaviors only. If the behavior threatens the personal safety of students, faculty or staff, or is displayed with such emotional intensity that it engenders fear or concern in others, immediately contact the Sheriff’s Office at (818) 710-4311 or call extension 4311 from any campus phone. Student Last name: name: Student ID No: Indicate your perceived level of risk: Mild Risk Moderate Risk Elevated Risk Non-urgent, informational only MILD RISK: Disruptive or concerning behavior. Student may or may not show signs of distress, No threat made or present. MODERATE RISK: More involved or repeated disruption, Behavior more concerning, Likely distressed or low-level disturbance, Possible threat made or present, Threat is vague and indirect, Information about threat or threat itself is inconsistent, implausible or lacks detail, Threat lacks realism, Content of threat suggests student is unlikely to carry it out. ELEVATED RISK: Seriously disruptive incident(s), Suspected substance abuse, Bizarre or unusual behavior indicating distress. Call Sheriff’s Office immediately. SEVERE RISK: Threat of harm to themselves or others: Call Sheriff’s Office immediately. Date(s) behavior was observed: Reason for referral: 1. Describe in clear and specific details the observed behavior(s). Do not make inferences, state only the facts. State specific words or phrases used and interactions. Describe tone of voice, facial expression, body stance, physical appearance, etc. 2. Your recommended action: For example, is this referral for information only? Do you think counseling is indicated? Disciplinary action? Any other thoughts? Please include your concerns and any conclusions you have drawn. 3. Please list other persons who may have witnessed the reported behavior: 4 Has the observed behavior been discussed with the student? (please explain) 5. Pierce Faculty/Staff making the referral: Name Title Office Phone: Cell: Email: To submit please save this document on your hard then email it to
Behavior%20Intervention%20Referral.docx