Intervention and Referral Request | Lawson State Community College

Read this statement before completing this form. Select "I understand" to verify you have read and understand the statement. STATEMENT: Use this form to submit a Referral or Intervention Request on Suspicious Behavior/Persons on Campus. IF THIS IS ON-CAMPUS EMERGENCY, DO NOT USE THIS FORM. CALL: 205-925-3587 (Birmingham Campus) or 205-426-3654 (Bessemer Campus). IF THIS IS AN OFF-CAMPUS EMERGENCY, CALL 911. IMPORTANT DISCLOSURE: Intentionally submitting a false report police may subject you to investigation or criminality.*

I understand

Your FIRST Name *

Your LAST Name *

Your relationship to the person of CONCERN. Select from the drop down menu. *

Your Phone/Cell #: *

Your Full Street Address*

Apartment Number, if applicable

City *

State/Province/Region *

Zip Code *

Country

Your Email Address: *

First Name of the Person of CONCERN. If you do not know, state: " I DO NOT KNOW" *

Last Name of the Person of Concern. If you do not know, state: "I DO NOT KNOW" *

Does the Person of Concern have a Nickname. If so, what it is? If you do not know, state: "I DO NOT KNOW" *

Gender of the Person of Concern:*

Male
Female

Approximate AGE of the Person of Concern. Select from the drop down menu. *

What is Your CONCERN related to this INDIVIDUAL? Select from the drop down menu provided.

What are the circumstances associated with the person of concern that have been reported or known to you personally. Select from the drop down menu.

Are there other Concerns NOT listed (please provide specifics):

If the person is taking a class with you, provide us with more details. What CLASS are you TAKING TOGETHER? Example: ENG101, MTH111, etc...

If you have the course CALL NUMBER, what is it? Example: 04563

What Campus?

What time does this class meet?

What building?

What is the room number?

What days does the class meet?

1-CLICK ACCESS BUTTONS

1-CLICK ACCESS BUTTONS

Campus Police