Health and Safety Referral Form

If you are concerned about the health, well being, or safety of a CSU student or CSU employee, you are encouraged to complete this form. Examples of why you may want to complete and forward the form include but are not limited to:

  • Threats, gestures, writings or attempts related to suicide or violence
  • Harmful to themselves or others
  • Self-injurious behavior (e.g. cutting self)
  • Alcohol or other substance abuse problems
  • Pattern of bizarre behaviors or actions
  • Hospitalization for mental health issues or drug or alcohol use
  • Sudden, rapid weight loss or gain
  • Poor health due to restrictive eating or concern this person has an eating disorder
  • Disruption to the living, learning or working environment

This is not a complete list. Please complete the form or call (970) 491-1350 if you have any reason to be concerned about a CSU community member’s health or safety.

DO NOT USE this referral form for any immediate crisis or emergency. Referrals will only be reviewed during normal business hours and may not be immediately reviewed. In the event of an emergency, call 911 or CSU Police at (970) 491-6425.

This form is designed to help the individual you are concerned about, not to punish them.

All reports will be treated with discretion and will be treated with a reasonable expectation of confidentiality. Information from this form may be shared with appropriate individuals in order to help protect the safety and health of those involved in any incidents reported.

You may remain anonymous when reporting through this form. However, it is very helpful to the university to have your contact information and name if there is a need to obtain more information about the situation or clarify information. In addition, without adequate information, the university may not be able to help. Therefore your contact information is strongly encouraged. Regardless, of whether you submit your name and contact information, every attempt will be made to review and address the concerns you submit on this form.


Information about the distressed individual







 


Information about the incident(s)

In the following boxes, please submit as much detail as possible about the incident or incidents that have caused you to be concerned about this person’s wellbeing or the wellbeing of others.


 


 


 

 

 

 

DO NOT USE this referral form for any immediate crisis or emergency - if this person has threatened to hurt themselves or others, immediately call 911 or CSU Police at (970) 491-6425.


 



 

 

Information about the person making this report










DO NOT USE this referral form for any immediate crisis or emergency. Referrals will only be reviewed during normal business hours. In the event of an emergency, call 911 or CSU Police at (970) 491-6425.

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