CARE Form

This form is intended to provide information about a member of the CIA student community about whom you are concerned. Please complete a separate form for any additional concern.

Basic Information

1. Your Full Name *This question is required.

2. Your Position: *This question is required.

Your Email Address

Student of Concern

Student ID # Student ID numbers are available to Faculty in their myCIA course roster's Printable Roster View.

Please list the individual relevant to this concern. Include as many of the listed fields as you can provide.

3. First Name: *This question is required.

Please list the individual relevant to this concern. Include as many of the listed fields as you can provide.

4. Last Name: *This question is required.

Nature of Concern

5. Please indicate the primary nature of the concern (choose one). *This question is required.