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Student Care Referral

Complete this form to refer concerns about currently enrolled students to the Student Care Team.

If this situation requires immediate attention, please contact the OTC Safety & Security Office at (417) 447-6911.

Reporter Contact Information

Your full name:

Your position/title:

Your phone number:

Your email address:

Email address must be of a valid format.

Office address (if applicable):

Nature of this report(Required):

This field is required.

Urgency of this report(Required):

This field is required.

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Select one

Date of incident(Required):

This field is required.

Time of incident:

Location of incident(Required):

This field is required.

Specific location:

Individuals of Concern

Please list students of concern below. For non-students, please list a SSN or Drivers License number in the Student ID field if known.

Involved party 1

Name of Individual

Select Gender

Select Role

Student ID

Incident Description

Please select any and all categories related to the concern for the student.(Required)

Stress/Anxiety

Mood dysregulation/depression

Atypical/Irregular classroom behavior

Problems/Issues with family

Personal relationship issues

Traumatic event

Death of family member/close friend

Sick or dying friend/family member

Medical emergency

Other

You must make at least one selection.

Please provide a detailed description of the incident/concern.(Required) This field is required.

Supporting Documentation

Photos, video, email, and other supporting documents may be attached below. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

Reporter Contact Information

Individuals of Concern

Incident Description

Supporting Documentation

Submission