STARs: The UMass Lowell Behaivoral Intervention Team

Student First Name

Student Middle Initial

Student Last Name

Student's ID #

Student's Email Address

Your Name

Your Title

Your Phone

Your Email Address

Your Relation to the Student

Date of Incident

Time of Incident

Location of Incident

Please provide a detailed description of the incident/behaviors you have observed. Use specific, concise, and objective language. Forward any additional information to the Dean of Students’ Office in Cumnock Hall and/or any electronic communication/supporting documentation to with the subject heading Student of Concern. Please call 978-934-2100 if you have additional questions.

Any effects/impacts of the behavior?

Any attempts to address the behavior & how the individual responded to the attempts?

Any other information about the individual that might seem relevant?