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Early Alert - Resource and Referral Request

If you are concerned about a student’s academics or personal well-being, please fill out as much information as possible in this form. Your submission will be triaged by Student Affairs and shared with the appropriate area for follow-up. Services include, but are not limited to, Counselling Services, Academic Advising, Accessibility Services, Financial Aid and Awards, and the Conduct and Care Office.

If this is an emergency do not use this form but call 911 or Campus Security at 250.740.6600 and/or consult with the Vancouver Island Crisis Line at 1.888.494.3888.

Please see the following website for more information and resources to support students in distress .

Your Contact Information

Your full name:

Your position/title:

Your phone number:

Your email address:

Email address must be of a valid format.

Time of incident:

Campus(Required):

This field is required.

Specific location:

Student Information

Involved party 1

Name

Student Number (if known)

Phone number (if known)

Email address (if known)

Concern

Area of Concern(Required)

Academic Concern Well-Being Concern Safety Concern Multiple Concern Areas Other Concern

You must make at least one selection.

Course Name (Academic Concern) This field is required.

Brief Overview of Concern(Required) This field is required.

We expect that you have made an attempt to connect with the student regarding your concerns. Have you been successful?(Required)

Yes No

You must make at least one selection.

Is there any reason we should not let the student know that you forwarded this concern when we reach out to them?(Required)

Yes No

You must make at least one selection.

Please let us know further details of this context requiring your anonymity: This field is required.

Additional Student Information (please check all that apply)

International Student Indigenous Student Residence Student Dual Credit or CTC Student

You must make at least one selection.

Submission

Email me a copy of this report