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

Company

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

Type of referral

Please select one of the following options(Required)

Person of concern referral (student conduct/behavioral issue)

Counseling support referral (mental health/connection to community support)

Title IX referral (sexual harassment/misconduct issue)

Hazing incident

Your information

Name(Required)

First Last

Phone

Enter Email Confirm Email

Student information

Name(Required)

First Last

Phone

Student ID#

Presenting concern / reason for referral

Please share the reason for the referral based on what you directly observed or experienced. When possible, focus on factual information rather than opinions, interpretations, or judgments.(Required)

Date of situation or observation(Required)

Setting or method of interaction (i.e. phone call, email, classroom, office / meeting, observation, etc.)

Type of referral

Your information

Student information

Presenting concern / reason for referral

Ready to learn more?