Vermont Tech  


Knights in the Know


Student Life


Vermont Tech IT Department
P.O. Box 500
Randolph Center, VT 05061
Service Desk

Care and Concern Form

Important: This form is not reviewed after hours, on weekends, during College vacations or student breaks.

If you need to report an emergency, please call Public Safety, 802.728.1292. Public Safety is available twenty-four hours a day, seven days a week.

This form may be used to share concerns about the behavior of a student, their health or a situation. Expressing concern shortly after an issue is raised or an incident occurs can help with early intervention and success.

When completing the form, please be as thorough, specific and objective, as possible. Anonymous reports are permitted, but we have found interventions are more effective when the student understands the genesis for the report including the name of the person sharing the concern. Reports which are not anonymous will be acknowledged and we may contact you for additional information. If you have questions or concerns or would like to speak with someone, please email Mary Kathryn Juskiewicz at or telephone, 802.728.1673

Thank you for sharing your concern.

* indicates a required field

Student(s) and, or person(s) involved. *

Description of concern, incident. Please be as specific as possible. *

Date of incident



Reporter's Name
If you do not wish to identify yourself you can leave this blank.

Reporter's Email

Reporter's Telephone

Confirmation of non-urgent nature of report. *

I understand this report will be received during normal business hours, 8:00AM – 4:30PM, Monday through Friday. For urgent concerns please call Public Safety, 802.728.1292.