Student referral / person of concern form

The safety and overall well-being of our students, faculty, and staff are important to us at Stark State College. Please use the form below to report any concerns related to student conduct, student mental and/or emotional issues, or any known/suspected sexual misconduct, stalking, or relationship violence involving a student, faculty, or staff member.

If you are reporting an act of violence, a physical threat, or mental health emergency please contact Campus Security immediately.

Main campus: 330-704-2582
Stark State Akron: 330-312-2526
Downtown Canton: 330-704-2522

Type of referral

Please select one of the following options

Your information

Name(Required)

First Last

Phone(Required)

Email(Required)

Enter Email Confirm Email

Student information

Name(Required)

First Last

Address

Street Address Address Line 2 City State ZIP Code

Phone

Email(Required)

Student ID#(Required)

Date of birth

Observation / incident details

Date of observation or incident(Required)

Time of observation or incident(Required)

Location of observation or incident(Required)

Presenting concern / reason for referral

Please provide a description of the behavior or incident observed.(Required)

This field is for validation purposes and should be left unchanged.