Employee of Concern Referral Form

If an employee's behavior is clearly reckless, disorderly, dangerous, or threatening and is suggestive of imminent harm to self or others in the community, call University Police immediately at 931-372-3234 or 911.

If indicators of distress are observed, but the severity is unclear or the interaction has left you feeling uneasy or concerned about the employee, contact the Counseling Center at 931-372-3331, 24/7.

Please submit this report form to help the Human Resources Team identify employees in need of assistance so we may provide interventions and resources to support the employee.

While anonymous reports are accepted, you are STRONGLY encouraged to provide your name and contact information so the Human Resources Team can request additional information or follow up, as necessary.

Your Name
Your Position/Title (if applicable)
Your Phone Number Your Phone Number - ### - ### ####
Your Email
Date of Incident (if applicable) Date of Incident (if applicable) / MM / DD YYYY
Time of Incident (if known) Time of Incident (if known) : HH MM AM/PM
Location of Incident (if known)
Referred Person Name
Referred Person's Department (if known)
Referred Person's Phone Number (if known) Referred Person's Phone Number (if known) - ### - ### ####
Referred Person's Email (if known)
Please provide a detailed description of the incident/behaviors you have observed. Use specific, concise, and objective language.
Were police involved?

Were police involved? Yes No Unknown
Was the Counseling Center or Eagle Eye Crisis Hotline contacted?

Was the Counseling Center or Eagle Eye Crisis Hotline contacted? Yes No Unknown
Photos, video, email, and other supporting documents may be attached below.

Attach Files