Student referral / person of concern form

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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.

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

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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

Email

Enter Email Confirm Email

Student information

Name(Required)

First Last

Phone

Email

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.)