Community Health Concern Report

Background Information

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Your full name:

Your position/title:

Your phone number:

Your email address:

Email address must be of a valid format.

Date of incident(Required):

This field is required.

Time of incident:

Location of incident(Required):

This field is required.

Specific location:

Involved Parties

Student Name

CCU ID#

Email address

Incident Information

Did you address your concern with the student?(Required)

Yes No

This field is required.

What behavior did you observe the student participating in?(Required)

Declined to wear a mask Refused to isolate/quarantine after diagnosis/directive Other major concern related to community health (please explain below)

You must make at least one selection.

If you selected "Other major concern related to community health" please explain. Otherwise, enter N/A.(Required) This field is required.

Provide a brief narrative about what you observed.(Required) This field is required.

Supporting Documentation

Photos, video, email, and other supporting documents may be attached below. 5GB maximum total size.
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Email me a copy of this report

Background Information

Involved Parties

Incident Information

Supporting Documentation

Submission