Read this statement before completing this form. Select "I understand" to verify you have read and understand the statement. STATEMENT: Use this form to submit a Referral or Intervention Request on Suspicious Behavior/Persons on Campus. IF THIS IS ON-CAMPUS EMERGENCY, DO NOT USE THIS FORM. CALL: 205-925-3587 (Birmingham Campus) or 205-426-3654 (Bessemer Campus). IF THIS IS AN OFF-CAMPUS EMERGENCY, CALL 911. IMPORTANT DISCLOSURE: Intentionally submitting a false report police may subject you to investigation or criminality.*


Your Full Street Address*


Gender of the Person of Concern:*


Are there other Concerns NOT listed (please provide specifics):