Student Concern & Comment Form

The purpose of this form is to keep Bellarmine University informed about student incidents and/or student well-being concerns. In addition, this form may be used to inquire about resources. Upon completion of form, please click 'submit'.

NOTE: The Bellarmine Concern Reports are checked regularly. However, if you need immediate assistance or if you feel yourself or someone else is in danger contact Bellarmine Public Safety at 502.272.7777 or 911.

General Student Concerns May Include:
- Mental health concerns
- Threatening behavior (toward self or others)
- Inappropriate behavior that made you/someone else uncomfortable
- Harassment of you or another student
- Hate speech directed at you or another person
- Bias, bigotry, hate directed toward you, another person, or property based on identity
- Sexual misconduct or harassment
- ADA or accessibility related issue
- Difficult family situation (domestic violence, homelessness, etc)
- You or someone you know needs assistance and are unsure where to go

Information shared on this form will be kept as private as possible and only those who are in a position to assist will be privy to it.

If you wish to speak with someone in person regarding this report or another concern, you are welcome to contact the Dean of Students Office 502.272.8150 or stop into Centro, Treece Hall, Room 225K or 225C.

Please note that there may be limitation in the level of response Bellarmine University is able to provide and share if there is a lack of information available.

Reporter's Information:

Person who witnessed and/or heard of the incident. Without this information, this concern will come through as anonymous and no direct follow-up to the reporting individual(s) will be possible.
Name of Reporting Party First Last
Phone Number ### - ### - ####
Email
Today's Date * MM / DD / YYYY
Impacted Individual's Information

If the person impacted is not the same person filling out this report, please include that person's information here:
Person(s) Involved (please include first & last name)
Email
Phone Number ### - ### - ####
Incident Description

Please provide a description of the incident to the best of your ability. The more information provided, the better capable the university is to appropriately respond.
Date of the incident * MM / DD / YYYY
Time of the incident * HH : MM : SS AM/PM
Location of the incident
Incident details *
Additional information you would like us to know
Do Not Fill This Out

Bellarmine University

Reporter's Information:

Impacted Individual's Information

Incident Description