MPCC CARE Team Intake Form

If this is an emergency, call 9-1-1 or contact Safety and Security at 344-8036 immediately.

The Mid-Plains Community College Campus Assessment, Response, & Evaluation (CARE) Team is dedicated to supporting MPCC students in distress and ensuring campus safety.

This form is for reporting concerns that may affect the health, safety, and welfare of Mid-Plains Community College (MPCC) students. If you are not sure that your concern meets the criteria for a CARE Team Concern, we encourage you to continue and submit your concern. 

For more detailed information on the MPCC CARE Team and when to make a report, visit the MPCC CARE Team webpage.

Who is submitting the concern?

Anonymous Reporting

Submitting this form anonymously is your decision to make.  However, please understand that if you choose to submit this report anonymously, the MPCC CARE Team inquiry into your concerns will be limited.

Reporter Name

Reporter Connection to MPCC

Reporter E-mail Address

Reporter Cell Phone Number

Who are you concerned about?

Please share information about the person(s) you are concerned about. If there are other persons involved, please include them as well. Complete as many of the listed fields as you are able.

Once you have added the information, click "Add Involved Individual". 

NOTE: You can add multiple individuals into this field by repeating this process as many times as needed.

Name

ID Number

Phone Number

Email Address

Involved Individual(s)

Why are you concerned?

I am concerned about the following behaviors (check all that apply):

Briefly describe the incident/concern. Please be as detailed as possible. Please include details including dates, times, and locations.

If you have taken steps to resolve the issue, please share them here using specific, concise, objective language.

Are you aware of any additional developments since the incident?

If yes, please describe the additional information her.

Is the individual aware that you are submitting this Concern Report to the College?

Do you have supporting documentation to share?

You can only attach one supporting document to this form. If you have more than one document to share please indicate that below and you will have the opportunity to share the documentation at a later time.

Photos, video, email, and other supporting documents may be attached below. 5GB maximum total size.