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Community Member of Concern Referral Form


Thank you for sharing your concerns for a community member at the University of Tennessee at Chattanooga. By sharing your concerns, you are helping to maintain UTC as a healthy and safe campus environment.

If you need to report a violation of the Student Code of Conduct; Policy on Sexual Harassment, Sexual Assault, Dating and Domestic Violence, and Stalking (Title IX); Bias-related Incidents; Residence Life Handbook; and/or other University policies, please visit: https://cm.maxient.com/reportingform.php?UTChattanooga. 

If you need to report a Faculty/Staff discrimination incident, please visit: https://www.utc.edu/finance-and-administration/equity-and-inclusion/compliance-and-equity.

If you need to report an Honor Code (Academic integrity) violation, please visit: https://cm.maxient.com/reportingform.php?UTChattanooga&layout_id=1.

BEFORE YOU BEGIN: If there is an immediate threat to self, others, or property immediately contact the UTC Police Department at (423) 425-HELP/4357 or 911. Although referrals are reviewed on a regular basis, this form is NOT designed as an emergency response notification process.

For assistance or consultation while completing this referral related to a student, please contact Student Outreach & Support at (423) 425-CARE/2273; select option '1' for student related concerns.

For assistance or consultation while completing this referral related to a faculty or staff member, please contact Human Resources at (423) 425-CARE/2273; select option '2' for faculty/staff related concerns.

Tell Us About You

You may file this report anonymously or by providing your contact information below. Please consider providing your contact information, as we may have additional questions regarding your report. Please note that all individuals evaluating this report are mandatory reporters as described by the University's Title IX policy.

 
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If known.

Who Was Involved

Please list the individuals involved, including as many of the listed fields as you can provide. For individuals who are not affiliated with UTC, please provide a Drivers License number in the block labeled UTC ID# if available. If you have listed your information as the person submitting the report, you DO NOT need to include your information below.

Involved party 1

Tell Us About Your Concerns

Please check any and all behaviors or issues below that have led you to be concerned about the individual involved. If no boxes apply, please use the text box below to describe your concerns in detail:(Required)
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Have you referred the community member to any campus resources? Please check all that apply.
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Supporting Documentation

Photos, video, email, and other supporting documents may be attached below. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

Submission