Early Alert Response System (EARS) Referral

* Required

Requirements

Referrals to the Early Alert Response System (EARS) assists EARS in determining appropriate strategies to respond to the reported concerns. The information provided is confidential and will only be shared with those with a legitimate educational interest.

Appropriate documentation requires thorough, detailed, factual and descriptive information.

Individual's Information

Check all of your Concerns









Behavioral


























Description of the Incident

**IMPORTANT** Please describe a specific incident or incidents involving the individual that relates to your concern.

Information that is specific and concrete should be provided with as little editorializing as possible, stressing only the individual’s concerning behavior.

  • INCLUDE
    • Nature of the incident
    • Behavior observed. (Be as specific as possible
    • Referrer
    • Dates
    • Times
    • Witnesses
    • Impact of the behavior
    • Action taken, if any
  • DO NOT INCLUDE
    • Psychological jargon of any type.
    • Diagnoses (e.g., “This person appears to be a “paranoid schizophrenic” or “This person is bipolar”.)
    • Speculation (e.g., “I think this person’s on drugs”)
    • Demeaning depictions (e.g., “She’s crazy” or “He’s not operating with a full deck”.

Other behaviors not listed above

This report submitted by

Note: Evidence to suggest false or misleading reports with intent to defame the character of another, may result in disciplinary actions

Developed: 11/2008
Revised: 08/2010

Choose your program