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Employee of Concern Reporting Form

This form is to be used to report concerning, threatening or worrisome behaviors by UIS employees.

IF THERE IS IMMEDIATE RISK TO LIFE OR PROPERTY
Call UIS Police 217-206-7777

Background Information

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Your full name:

Your position/title:

Your phone number:

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XXX-XXX-XXXX

Your email address:

Email address must be of a valid format.

Your physical address:

Date of Incident(Required):

This field is required.

Time of Incident:

Specific Location:

Subject of Report

Involved party 1

Full Name

UIN, if known

Phone number

Email address

Title and Work Location

Questions

I am concerned about the following behaviors (check all that apply)(Required)

Thoughts of Suicide

Alcohol Use/Drug Use

Suspicion of Self Harm

Missing Work

Threats Against Others

Acts of Violence

Violence Ideation

Pattern of Physical or Emotional Bullying and/or Intimidation

Unwelcome Sexual Advances

Harms or Destroys Property

Inappropriate Attempts to Control Processes, Outcomes or Decisions

Non-Compliance to University Health and Safety Behaviors

Fixation on Injustice

Delusional Ideation or Behaviors (Persecutory, Paranoia, Hallucinations)

You must make at least one selection.

How would you prefer we contact you for follow up?(Required)

Phone Email Message

This field is required.

Please provide a description of the concern(s):(Required) This field is required.

Supporting Documentation

Photos, video, email, and other supporting documents may be attached below. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

Submission

Email me a copy of this report