General Information

Person being referred:

(First name if known) (Last name if known)

Status:

StudentFacultyStaffVisitor

Gender:

MaleFemale

General description
of the individual:

Person making referral:

(First Name) (Last Name)

Phone:

Email:

Date of incident:

(Day of Week) (Month/Day/Year)

Occurred/behavior observed:

Time

AMPM

Have you advised the person of this referral?

YesNo

If no, please explain:

Description of the incident:
Please provide a detailed description of the incident/observed behaviors. Include
the names of any witnesses and their contact information, if available.
Be specific; record behaviors, not assumptions.

Tobacco-Free Incident Referral Form