Coastal Care Form : Coastal Alabama Community College

Person Providing Information

First Name

Last Name

Your relationship to the person of concern

Phone

Address

City

State

Zip Code

The Person of Concern Information

First Name

Last Name

Possible Nickname

Gender

Approximate Age

If the person is in a class with you or you know of a class that they are taking, please include the following:

Campus

Building

Room

Date

Immediate Needs

Check all that apply

Assistance with housing

Assistance with clothing

Assistance with food

Type of Concerning Behavior

Check all that apply

Significant change in personal hygiene or appearance

Significant change in energy level

Change in mood, personality or behavior

Withdrawn –Complaints of fatigue

Inability to focus or concentrate

Unusual or erratic performance, speech behaviors

Significant change in weight

Threat of self-harm

Visible Injuries - cuts, burns, etc.

Farewell statements alluding to not ever seeing people again

Tearfulness or repeated episodes of crying

Giving away prized possessions

Feeling of hopelessness

Expressions of worthlessness

Difficulty controlling emotions

Academic or workplace performance concerns

Excessive absenteeism / missing scheduled classes or appointments

Tardiness to class or appointments

Comments related to sleeping issues / nightmares

Direct threats toward an individual or individuals

Displays unprovoked anger, aggression or hostility

Unusual writing or drawings

Demanding

Inappropriate outburst or reactions

Intimidating

Preoccupation with violence

Expressions of worry or anxiety

Feeling suspicious of others

Suspected drug or alcohol abuse

Odor of alcoholic beverage

Cultural factors

Problems making friends

Stares inappropriately at others

Invades personal space of others

Makes unwanted physical contact

Abusive to animals

Preoccupied with fire

Please indicate selections from the relevant category/categories. Circumstances associated with the person of concern that have been reported or known to you personally.

Check all that apply

Is not engaged in seeking treatment for diagnosed health condition

History of alcohol/drug abuse

Has suffered personal or financial loss

Destruction of property

Fire setting or arson

Suffered childhood abuse or neglect

Suffered sexual assault or abuse

Committed sexual assault or abuse

Victim- history of relationship/domestic violence

Offender- history of relationship/domestic violence

Fantasy of harming people

History of planning a violent event

Fascination with weapons

Owns or has access to weapons

Has made homicidal statements

History of violent, reckless or antisocial behavior

History of suicide attempt

Other (Please provide details below)

None of these apply

Other - Please type your details below.

Indicators & Behaviors of Suspected Terrorists

Check all that apply

Breach/Attempted Intrusion - Unauthorized personnel; attempting to enter or actually entering secured area.

Misrepresentation - Presenting False information or misusing insignia, documents, and documents, and/or identification misrepresent one's affiliation as a means of concealing possible illegal activity.

Theft/Loss/Diversion - Steeling or diverting something associated with a facility/infrastructure for the purpose of committing an act of terrorism.

Cyberattack – Compromising or attempted to compromise or disrupt an organization’s information technology infrastructure.

Expressed or Implied Threat – Communicating a spoken or written threat to commit a crime that will result in death or bodily injury to another person or persons or to damage or compromise a facility.

Aviation Activity – Learning to operate or operating an aircraft in a manner that poses a threat of harm to people or property.

Eliciting Information – Questioning individuals at a level beyond mere curiosity about events, facilities, and related security procedures.

Testing or Probing of Security – Deliberate interactions with people or installations for the purpose of revealing security capabilities or weaknesses.

Recruiting/ Financing – Providing direct financial support and or assistance to a terrorist group.

Photography- Taking pictures of facilities or buildings in an unusual manner that would be arouse suspicion in a reasonable person.

Observation /Surveillance – Demonstrating unusual prolonged interest in a facility beyond casual or professional interest.

Material Acquisition / Storage – Acquiring and or storing unusual quantities of materials for use in unlawful activities.

Acquisition of Expertise – Attempts to obtain or conduct training in security concepts, military weapons or tactics for other than lawful purposes.

Weapon Collection / Discovery- Collection of unusual amounts of weapons, ammunition, explosives, or toxic chemicals for other than lawful purposes.

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Early Alert Form Student

Person Providing Information

The Person of Concern Information

If the person is in a class with you or you know of a class that they are taking, please include the following: