General Referral Form

Background Information

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Your Full Name:

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Or, you may write Anonymous

Your Position/Title:

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Or, you may write N/A

Your Phone Number:

Your Email Address:

Email address must be of a valid format.

Your Physical Address:

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On Campus Residence/Office (if applicable)

Nature of This Report(Required):

This field is required.

Date of Incident(Required):

This field is required.

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mm/dd/yyyy

Time of Incident:

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00:00 AM/PM

Location of Incident(Required):

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Specific Location:

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For example, room or office number.

Involved Parties

Please list the individuals involved (excluding yourself), including as many of the listed fields as you can provide. For non-students, you may list a drivers license or other ID number in the field labeled "Seattle U ID Number."

Involved party 1

Name or Organization

Select Role

Seattle U ID Number (7 digits)

DOB (YYYY-MM-DD)

Phone Number

Email Address

On Campus Building/Room (if applicable)

Incident or Referral Information

Please include as much specific and objective detail as possible, including the who, what, when, and where in your incident report/referral narrative.

List first and last names of any staff members (i.e., Residence Life staff, Public Safety officers) who responded to the situation (if applicable). This field is required.

Incident Report or Referral Narrative:(Required) This field is required.

Did Seattle U Public Safety, medical services, and/or a law enforcement agency respond?(Required)
Yes No I Don't Know
This field is required.

Supporting Documentation

Upload any relevant documentation or attachments. 1GB maximum total size. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

Submission