Submit a BIT Referral

Please fill out the information below to submit a behavioral intervention referral.

If you see this don't fill out this input box.

* Reporter's Name:

* Reporter's Email:

* Reporter's Phone:

* Time of Incident:

* Date of Incident:

* Location of Incident:

Please provide any additional location details (for example: in the 3rd floor lobby, A-256, etc.):

* Please list the name(s) (and contact information if known) of the student(s) involved in this situation:

Please list the name(s) (and contact information if known) for all witnesses to this situation:

* Please provide as much information as possible about the situation, including any action taken: