Division of Student Affairs BETA Team

Behavioral Concern Report

Complete the following form to report a student exhibiting behavior of concern and to seek evaluation by the Behavioral Evaluation & Threat Assessment Team. A Behavioral Concern Report may be submitted anonymously; however, this may affect the University’s ability to fully evaluate the behavioral concern. In the alternative, the person filing a report may request that his or her identity remain confidential to the degree possible.

Note that for immediate threat of violence or substantial disruption contact the Department of Public Safety at 911 or 301.314.3333.

Person Filing Report (items with * are required)

Name:
*University Affiliation:
Telephone: (format 3014051000)
Email:

Student Exhibiting Behavior of Concern

*Student Name:
Student ID (if known):
Student Email (if known): 

Incident/Behavior Description

Date of Incident:
Time of Incident:
Location of Incident:

*Please provide a detailed description of the incident or situation that has caused you to file a report for possible behavioral intervention.  Additional supporting material such as electronic mail or other documents may be sent separately to BETA Team chair, John Zacker, by email at jzacker@umd.edu or campus mail at 2118 Mitchell Building.