Chicago State University

This online submission will go directly to the Office of the Associate Vice President of Student Affairs. The Associate Vice President of Student Affairs will identify resources and personnel best suited to address the concern articulated. The ultimate goal is to provide proactive support services to distressed students before more substantial problems potentially arise.

Reporter Information

* indicates required fields minlength:1 Please enter reporter first name minlength:1 Please enter reporter last name minlength:1 Please enter relationship to student minlength:1 Please enter reporter status minlength:1 Please enter cell or office phone minlength:1 Please enter email Student of Concern Information legend=true; Please enter as much information related to the student as possible legend=true; minlength:1 Please enter student's first name minlength:1 Please enter student's last name minlength:1 Please enter student's ID Concern Information legend=true; minlength:1 Please enter date of initial concern Please select all that apply from the below: legend=true; addclass=bold; addclass=bold; Behavioral/Social/Emotional legend=true; addclass=bold; addclass=longfield; addclass=longfield; addclass=longfield; Thanks for submitting your request. Something Bad Happened. {{Email}} Student Concern Form Thank You for Your Submission {{Email}} Student Concern Form Reporter First Name: {{ReporterFirstName}} Reporter Last Name: {{ReporterLastName}} Relationship to Student: {{RelationshiptoStudent}} Reporter Status: {{ReporterStatus}} Reporter's Department/College: {{ReportersDepartmentCollege}} Cell or Office Phone: {{CellorOfficePhone}} Email Address: {{Email}} Student's First Name: {{StudentsFirstName}} Student's Last Name: {{StudentsLastName}} Student's ID: {{StudentsID}} Cell or Home Phone: {{CellorHomePhone}} Email Address: {{EmailAddress}} Date of Initial Concern: {{DateofInitialConcern}} Location of Initial Concern: {{LocationofInitialConern}} Academic: {{Academic}} Physical: {{Physical1}} Anxiety: {{Anxiety}} Other: {{Other}} Get Involved/learn about concern: {{anyonegetinvolved}} Step you have taken/address your concern: {{Whatstepshaveyoutakenifanytoaddr}}

Follow-up Request

Reminder: In order to provide effective responses for students concerns you may be contacted for additional information. Our online submission process will allow us to receive and respond to reports promptly. By completing this form the reporter agrees to maintain all confidentiality of the information reported. Additionally, full disclosure concerning the student’s progress may be limited due to the student’s privacy rights.