PharmD Student Support Request

Your information

First Name*

Last Name*

Email*

Phone*

How do you know the student?

Information about the student

Student's First Name*

Student's Last Name*

Student’s UW Email*

If available, enter the student's UW ID number.

If you have been successful in contacting the student, please list the email(s) and phone number(s) information you used.

What actions, if any, have you taken so far? (Select all that apply)*

Communicated with the student
Communicated with other staff/faculty
Provided resources to the student
Submitted/Intend to submit a UW Care Report
Called UW SafeCampus
Called 911, 988, or 211
None, this is the first action I've taken
Contacted the student's academic advisor
Other

Please list the advisor’s name*

Other

General description of your reasons for requesting support for this student. Please include as much detail as you can, including observed behaviors or issues leading to the concern, approximate dates, etc.*

Please note that we may contact you for more information and to follow up.

I understand this form is not meant to address emergency situations. Response time is typically 24-72 hours. For urgent situations, SafeCampus provides a list of 24/7 UW and community resources.*

I understand