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Apply
Apply
Intervention Request Form
(Optional) Person Providing Information
Although not required, you may enter information about yourself below. This will remain confidential and only be shared with employees who need to know for intervention purposes, as necessary.
Name of Person Reporting
First
Last
Please choose which best describes you:
I am a student/cadet.
I am a faculty/staff member.
Your relationship to the person of concern
Relative
Classmate
Instructor/Staff
No Relation
Your Phone Number
Your Address
Street Address
City
State / Province / Region
ZIP / Postal Code
Your Email Address
Person of Concern Information
Name
First
Last
Possible Nickname
Approximate Age
If you know which barracks they are in, please select here:
Trustees Hall (Alpha Company Barracks)
Lovelace Hall (Bravo Company Barracks)
Rane Hall (Charlie Company Barracks)
Wilkerson Hall (Delta Company Barracks)
Murfee Hall (Echo Company Barracks)
Which floor?
Which room?
If the person is in a class with you or you know of a class that they are taking, please include the following:
Please choose which building:
North Academic Wing (Right side of Chapel)
South Academic Wing (Left side of Chapel)
Administration Building
Alumni Gymnasium/Fitness Center/Weight Room
Baer Memorial Library
Bookstore/Mailroom
Chapel
Dining Hall
Guardhouse
Ireland Athletic Center/Gym/Pool
Johnson Hall
Middlebrooks Hall/Music Building
Monteabaro Complex/Chemistry Building
Robinson Excess House
Other
If you need to lookup the name of the building, please view the campus map: https://marionmilitary.edu/about-mmi/campus-map/
Please enter the floor and/or room number, if applicable
Please describe the location here:
Date
MM slash DD slash YYYY
Time
:
Hours
Minutes
AM
PM
AM/PM
Immediate Needs
Check all that apply
Assistance with housing
Assistance with clothing
Assistance with food
Type of Concerning Behavior
Check all that apply
Significant change in personal hygiene or appearance
Significant change in energy level
Change in mood, personality or behavior
Withdrawn –Complaints of fatigue
Inability to focus or concentrate
Unusual or erratic performance, speech behaviors
Significant change in weight
Threat of self-harm
Visible Injuries - cuts, burns, etc.
Farewell statements alluding to not ever seeing people again
Tearfulness or repeated episodes of crying
Giving away prized possessions
Feeling of hopelessness
Expressions of worthlessness
Difficulty controlling emotions
Academic or workplace performance concerns
Excessive absenteeism / missing scheduled classes or appointments
Tardiness to class or appointments
Comments related to sleeping issues / nightmares
Direct threats toward an individual or individuals
Displays unprovoked anger, aggression or hostility
Unusual writing or drawings
Demanding
Inappropriate outburst or reactions
Intimidating
Preoccupation with violence
Expressions of worry or anxiety
Feeling suspicious of others
Suspected drug or alcohol abuse
Odor of alcoholic beverage
Cultural Factors
Problems making friends
Stares inappropriately at others
Invades personal space of others
Makes unwanted physical contact
Abusive to animals
Preoccupied with fire
Please indicate selections from the relevant category/categories. Circumstances associated with the person of concern that have been reported or known to you personally.
Check all that apply
Is not engaged in seeking treatment for diagnosed health condition
History of alcohol/drug abuse
Has suffered personal or financial loss
Destruction of property
Fire setting or arson
Suffered childhood abuse or neglect
Suffered sexual assault or abuse
Committed sexual assault or abuse
Victim- history of relationship/domestic violence
Offender- history of relationship/domestic violence
Fantasy of harming people
History of planning a violent event
Fascination with weapons
Owns or has access to weapons
Has made homicidal statements
History of violent, reckless or antisocial behavior
History of suicide attempt
Other (Please provide details below)
None of these apply
Other - Please type details below
Indicators & Behaviors of Suspected Terrorists
Check all that apply
Breach/Attempted Intrusion - Unauthorized personnel; attempting to enter or actually entering secured area.
Misrepresentation - Presenting False information or misusing insignia, documents, and documents, and/or identification misrepresent one's affiliation as a means of concealing possible illegal activity.
Theft/Loss/Diversion - Steeling or diverting something associated with a facility/infrastructure for the purpose of committing an act of terrorism
Cyberattack – Compromising or attempted to compromise or disrupt an organization’s information technology infrastructure.
Expressed or Implied Threat – Communicating a spoken or written threat to commit a crime that will result in death or bodily injury to another person or persons or to damage or compromise a facility.
Aviation Activity – Learning to operate or operating an aircraft in a manner that poses a threat of harm to people or property.
Eliciting Information – Questioning individuals at a level beyond mere curiosity about events, facilities, and related security procedures.
Testing or Probing of Security – Deliberate interactions with people or installations for the purpose of revealing security capabilities or weaknesses.
Recruiting/ Financing – Providing direct financial support and or assistance to a terrorist group.
Photography- Taking pictures of facilities or buildings in an unusual manner that would be arouse suspicion in a reasonable person.
Photography- Taking pictures of facilities or buildings in an unusual manner that would be arouse suspicion in a reasonable person.
Material Acquisition / Storage – Acquiring and or storing unusual quantities of materials for use in unlawful activities.
Acquisition of Expertise – Attempts to obtain or conduct training in security concepts, military weapons or tactics for other than lawful purposes.
Weapon Collection / Discovery- Collection of unusual amounts of weapons, ammunition, explosives, or toxic chemicals for other than lawful purposes.
Anonymity Statement
The Behavioral Intervention Team (BIT) will automatically receive a copy of this report. No information regarding the reporter's identity will be shared with anyone outside of the Behavioral Intervention Team (BIT).
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