COM CARE Report | College Forms

Welcome to the COM CARE Report Form
IF THIS IS AN EMERGENCY SITUATION CALL 911

Important: Please use Google Chrome Browser to complete this report.

This CARE Report will help the College of Marin CARE Team and other appropriate staff intervene with the individuals with whom you are concerned. We greatly appreciate the information you will provide below. Rest assured, it will only be shared on a need-to-know basis within Federal Education Rights & Privacy Act (FERPA) guidelines. We will also make appropriate efforts to keep you informed about the status of the individual as we work with them. If you have questions about the actions taken or the status of your report, do not hesitate to reach out to the CARE Team. This form for use only by College of Marin faculty, staff, and students.

For questions about this form, please contact the Student Activities and Advocacy Office at (415) 485-9376.

If you need accommodations completing this form, please reach out to Student Accessibility Services at (415) 485-9406 or by emailing sas@marin.edu.

RESOURCES:
• Community Action Marin - https://camarin.org/service/safety-net/
Schedule an orientation by calling this number, 415-526-7500.
• Please go to: https://www.211bayarea.org/ to see local food access locations near you.
• For families with young ones, please go to this link for diapers and baby essentials in Marin: https://www.postpartumsc.org/marin-diaper-bank
• For folks who need feminine hygiene products, please contact our Health Center to make an appointment to pick up any items you may need: http://ss.marin.edu/health-services
• If you are a victim of domestic violence, please contact the Center for Domestic Peace by calling their 24-hour hotline at 415-924-6616 or visit their website at: https://centerfordomesticpeace.org/
• 988 - Suicide & Crisis Lifeline: call 988 or visit their website at: https://988lifeline.org/

NOTE: The College of Marin will be closed on Fridays during summer. Our system will not be monitored during those days. Please know that your report is important to us, and we will respond as soon as we are available. If this is an emergency, please call 911.

For questions about this form, please contact the Student Activities and Advocacy Office at (415) 485-9376.

Care Report *

Name *

Please provide your full name.

E-mail *

Please provide your email address so that we can contact you if we have follow up questions about this report.

Your Phone *

Please provide your phone number so that we can contact you if we have follow up questions about this report.

Your COM Affiliation *

Please provide your affiliation to the College of Marin.

What is the COM Affiliation of the individual involved? *

Individual(s) Involved (Please provide the name, M00#, phone and email of the individual(s) involved) *

Descriptive Information

Date of Incident *

Month

Day

Year

Time of Incident

Hour

:

Minute

am

pm

Which location did this incident occur? *

Kentfield Campus

Indian Valley Campus

Off-Campus

Additional Location Information

If applicable, please provide any additional location details (for example: in the 3rd floor lobby).

DescriptionRequired

Narrative: Using specific, concise, and objective language, please describe the incident/concern (who, what, when, where, why, and how)

COM Next Steps *

Please consult with me before contacting the involved individual(s).

Please do not take action/document incident only.

Please proceed with intervention.

Please indicate what you would like done with this report. Please note that the District retains discretion when/if action is taken with all submitted reports.

Rate Your Level of Concern *

Mild

Moderate

Severe

Please rate the level of concern you have for this individual.

Certification *

By checking this box

I certify that the information given in this report is true and correct to the best of my knowledge or belief.