NEIU Behavioral Concerns Team (BCT)

Report of Incident or Concern

You can report a behavioral incident or concern either by completing this form or by contacting a member of
the BCT by telephone or email. Please be as concise and objective as possible when completing this form.
Not all fields may apply to your report; answer each of the following questions to the best of your knowledge.
If this is an emergency, call University Police at 773.442.5511.

Date of incident (if applicable):
Time of incident (if applicable):
Location of incident (if applicable):

Information about the Person who causes you concern

Name (if known):
Nickname (or AKA):
Description of person (height, weight, hair color, skin tone, gender, clothing, etc.):

Person of Concern's Phone (if known)
E-mail (if known)
Student ID# (if known)
University status: If other, please specify:

Your contact information

Your Name:
Is it OK to contact you? Preferred contact method:
Your contact information: Phone E-mail
Your University status: If other, please specify

Information about the incident or concern

Was a police report made regarding this? (If so, report #):

Description of incident (please be specific and objective):

Other people involved:

Others' contact information (if known):

Any additional information about the person, incident or concern:

Click the submit button to send this report to the NEIU Behavioral Concerns Team.
Thank you for your concern and your responsiveness.