Intervention Request Form

What Type of Request is This?*
IF YOU NEED TO REPORT AN EMERGENCY, PLEASE CLOSE THIS FORM AND DIAL 911 OR 334-683- NOW. Otherwise, please let us know if this request is urgent (needs to be addressed within 24 hours) or non-urgent (can be addressed soon, but not immediately).
- Urgent - This request is time-sensitive and needs to be addressed within 24 hours.
- Non-urgent - This request needs to be addressed soon, but is not time-sensitive.

Urgent Request Form
Describe Request*
Please describe your urgent request here using as many details as you can (people involved, location, dates and times, etc.).
Please provide your name.
First Last
Please provide the best phone number to use to contact you about your request.
Non-Urgent Request
Name of Person Reporting
Although not required, you may enter information about yourself below. This will remain confidential and only be shared with employees who need to know for intervention purposes, as necessary.
First Last
Please choose which best describes you:
- I am a student/cadet.
- I am a faculty/staff member.
Your relationship to the person of concern
Your Phone Number
Your Address
Street Address City State / Province / Region ZIP / Postal Code
Your Email Address
Person of Concern Information
Name
First Last
Possible Nickname
Approximate Age
If you know which barracks they are in, please select here:
Which floor?
Which room?

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