Penguin of Concern Referral Form

Background Information

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Your full name:

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If you prefer to remain anonymous, you may leave this section blank.

Your position/title:

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What is your connection with this individual or group?

Your phone number:

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Where can you be reached if we have additional questions about your concern?

Your email address:

Email address must be of a valid format.

Nature of this report(Required):

This field is required.

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Select a PRIMARY REASON for the report below; the reasons are defined as follows:

Is this a self-referral?(Required):

This field is required.

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Are you the student that needs assistance?

Date of issue/concern(Required):

This field is required.

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If applicable

Time-frame of issue/concern:

Where did the incident occur?(Required):

This field is required.

Specific location:

Penguin(s) of Concern

Name

Gender

Role/Campus Affiliation

Y Number (if known)

DOB (YYYY-MM-DD) (if known)

Phone Number (if known)

Email Address (if known)

Hall/Address (if known)

Questions

Please answer the following questions and check all applicable boxes.

By selecting this checkbox, you certify that if this situation involves a potential health or safety emergency, you are completing this referral form AFTER contacting emergency services directly for assistance (911 from a campus phone or 330-941-3527 from a mobile phone for YSUPD).(Required)

Yes, I certify.

You must make at least one selection.

Please describe the reason for your referral. Enter as much information as possible about the incident or your concern. Include relevant dates and use direct quotes when appropriate.(Required) This field is required.

Have any actions been taken to address this issue/concern or has the individual/group been referred to any other campus or community resource(s)? If yes, please describe/list. This field is required.

Does this individual/group have other known connections to the campus community (e.g. Athletics - Specify Team, International, Greek Life, Student Employee, Veteran, ROTC, Band/Choir, Peer Mentor, Orientation Leader, Foster Care System, College Credit Plus "CCP", Early College, Campus Housing, or other)? If yes, please describe. This field is required.

Do you have any concern about someone from the Office of the Dean of Students, the YSU CARE Team, or other appropriate resource reaching out to this individual/group (i.e. safety concern, domestic abuse situation, etc.)? If yes, please explain. This field is required.

If your concern is related to mental health, would you like someone from Student Counseling Services to reach out to schedule a consultation/conversation (if deemed appropriate)?(Required)

No Unsure Yes (via phone - provide student phone number below) Yes (via email - provide student email below)

You must make at least one selection.

Preferred student phone and/or student email (for SCS outreach) This field is required.

Concerns related to finances may be best addressed by YSU's Penguin Service Center (PSC). Are you comfortable with the Dean of Students (DOS) forwarding this report to the PSC staff for initial outreach?

Yes, I am comfortable receiving initial outreach from the PSC (if deemed appropriate) No, I prefer to receive initial outreach from DOS staff No, I prefer to reach out to the PSC directly (https://ysu.edu/penguin-service-center)

You must make at least one selection.

Is it ok for us to let the person(s) of concern know that you referred them or do you prefer to remain anonymous?(Required) This field is required.

If you stated that you prefer to remain anonymous, please explain why in the box below. This field is required.

Supporting Documentation

Please attach any photos, video, email, social media posts, etc., as appropriate. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

Email me a copy of this report

Background Information

Penguin(s) of Concern

Questions

Supporting Documentation

Submission