{"id":16837,"date":"2026-07-16T08:51:40","date_gmt":"2026-07-16T12:51:40","guid":{"rendered":"https:\/\/carleton.ca\/esp\/?page_id=16837"},"modified":"2026-07-16T08:51:41","modified_gmt":"2026-07-16T12:51:41","slug":"incident-concern-report-form","status":"publish","type":"page","link":"https:\/\/carleton.ca\/esp\/incident-concern-report-form\/","title":{"rendered":"Incident\/Concern Report Form"},"content":{"rendered":"\n<section class=\"w-screen px-6 cu-section cu-section--white ml-offset-center md:px-8 lg:px-14\">\n    <div class=\"space-y-6 cu-max-w-child-5xl  md:space-y-10 cu-prose-first-last\">\n\n            <div class=\"cu-textmedia flex flex-col lg:flex-row mx-auto gap-6 md:gap-10 my-6 md:my-12 first:mt-0 max-w-5xl\">\n        <div class=\"justify-start cu-textmedia-content cu-prose-first-last\" style=\"flex: 0 0 100%;\">\n            <header class=\"font-light prose-xl cu-pageheader md:prose-2xl cu-component-updated cu-prose-first-last\">\n                                    <h1 class=\"cu-prose-first-last font-semibold !mt-2 mb-4 md:mb-6 relative after:absolute after:h-px after:bottom-0 after:bg-cu-red after:left-px text-3xl md:text-4xl lg:text-5xl lg:leading-[3.5rem] pb-5 after:w-10 text-cu-black-700 not-prose\">\n                        Incident\/Concern Report Form\n                    <\/h1>\n                \n                                \n                            <\/header>\n\n                    <\/div>\n\n            <\/div>\n\n    <\/div>\n<\/section>\n\n\n\n\n<script>\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof 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0.65)'\/%3E%3C\/svg%3E\");--gf-label-space-y-secondary: var(--gf-label-space-y-lg-secondary);--gf-ctrl-border-color: #cccccc;--gf-ctrl-size: var(--gf-ctrl-size-lg);--gf-ctrl-label-color-primary: #112337;--gf-ctrl-label-color-secondary: #112337;--gf-ctrl-choice-size: var(--gf-ctrl-choice-size-lg);--gf-ctrl-checkbox-check-size: var(--gf-ctrl-checkbox-check-size-lg);--gf-ctrl-radio-check-size: var(--gf-ctrl-radio-check-size-lg);--gf-ctrl-btn-font-size: var(--gf-ctrl-btn-font-size-lg);--gf-ctrl-btn-padding-x: var(--gf-ctrl-btn-padding-x-lg);--gf-ctrl-btn-size: var(--gf-ctrl-btn-size-lg);--gf-ctrl-btn-border-color-secondary: #cccccc;--gf-ctrl-btn-bg-color-hover-tertiary: #EBEBEB;--gf-field-img-choice-size: var(--gf-field-img-choice-size-md);--gf-field-img-choice-card-space: var(--gf-field-img-choice-card-space-md);--gf-field-img-choice-check-ind-size: var(--gf-field-img-choice-check-ind-size-md);--gf-field-img-choice-check-ind-icon-size: var(--gf-field-img-choice-check-ind-icon-size-md);--gf-field-pg-steps-number-color: rgba(17, 35, 55, 0.8);}<\/style>\n                        <div class='gform_heading'>\n                            <p class='gform_description'>This form is used to document concerns related to an ESP student&#8217;s well-being, behaviour, accessibility barriers, or safety. It is also used to ensure appropriate follow-up, communication, and accountability. If a student is at risk of harming themselves or others, call Campus Safety at 613-520-4444.\r\n\r\nPlease note that according to privacy legislation students have the right to request a copy of this report.<\/p>\n                        <\/div><form class='not-prose' method='post' enctype='multipart\/form-data'  id='gform_79'  action='\/esp\/wp-json\/wp\/v2\/pages\/16837' data-formid='79' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_79' class='gform_fields top_label form_sublabel_below description_below validation_below'><fieldset id=\"field_79_3\" class=\"gfield gfield--type-name gfield--input-type-name gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Your Name<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name has_middle_name has_last_name has_suffix gf_name_has_4 ginput_container_name gform-grid-row' id='input_79_3'>\n                            \n                            <span id='input_79_3_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_3.3' id='input_79_3_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_79_3_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            <span id='input_79_3_4_container' class='name_middle gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_3.4' id='input_79_3_4' value=''   aria-required='false'     \/>\n                                                    <label for='input_79_3_4' class='gform-field-label gform-field-label--type-sub '>Chosen name(s) &#8211; optional<\/label>\n                                                <\/span>\n                            <span id='input_79_3_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_3.6' id='input_79_3_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_79_3_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            <span id='input_79_3_8_container' class='name_suffix  gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_3.8' id='input_79_3_8' value=''   aria-required='false'     \/>\n                                                    <label for='input_79_3_8' class='gform-field-label gform-field-label--type-sub '>Pronouns &#8211; optional<\/label>\n                                                <\/span>\n                        <\/div><div class='gfield_description' id='gfield_description_79_3'>Please put the pronouns that you wish your coworkers to use when referring to you. Our standard practice is to include your pronouns with your profile on our website. This field can be updated at any time by emailing <a href=\"mailto:ESPFacilitators@carleton.ca\">ESPFacilitators@carleton.ca<\/a>.<\/div><\/fieldset><div id=\"field_79_5\" class=\"gfield gfield--type-email gfield--input-type-email gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_79_5'><span class='gform-field-label__text'>Carleton Email Address<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_5' id='input_79_5' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><fieldset id=\"field_79_6\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Your Role at ESP<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_79_6'>\n\t\t\t<div class='gchoice gchoice_79_6_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_6' type='radio' value='Academic Coach'  id='choice_79_6_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_79_6_0' id='label_79_6_0' class='gform-field-label gform-field-label--type-inline'>Academic Coach<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_79_6_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_6' type='radio' value='Facilitator'  id='choice_79_6_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_79_6_1' id='label_79_6_1' class='gform-field-label gform-field-label--type-inline'>Facilitator<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_79_6_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_6' type='radio' value='Mentor'  id='choice_79_6_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_79_6_2' id='label_79_6_2' class='gform-field-label gform-field-label--type-inline'>Mentor<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_79_6_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_6' type='radio' value='Staff'  id='choice_79_6_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_79_6_3' id='label_79_6_3' class='gform-field-label gform-field-label--type-inline'>Staff<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_79_6_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_6' type='radio' value='gf_other_choice'  id='choice_79_6_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_79_6_4' id='label_79_6_4' class='gform-field-label gform-field-label--type-inline'>Other<\/label><br \/><input id='input_79_6_other' class='gchoice_other_control' name='input_6_other' type='text' value='Other' aria-label='Other Choice, please specify'  disabled='disabled' \/>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_79_7\" class=\"gfield gfield--type-name gfield--input-type-name gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Student Name<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name has_middle_name has_last_name has_suffix gf_name_has_4 ginput_container_name gform-grid-row' id='input_79_7'>\n                            \n                            <span id='input_79_7_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_7.3' id='input_79_7_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_79_7_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            <span id='input_79_7_4_container' class='name_middle gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_7.4' id='input_79_7_4' value=''   aria-required='false'     \/>\n                                                    <label for='input_79_7_4' class='gform-field-label gform-field-label--type-sub '>Chosen name(s) &#8211; optional<\/label>\n                                                <\/span>\n                            <span id='input_79_7_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_7.6' id='input_79_7_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_79_7_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            <span id='input_79_7_8_container' class='name_suffix  gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_7.8' id='input_79_7_8' value=''   aria-required='false'     \/>\n                                                    <label for='input_79_7_8' class='gform-field-label gform-field-label--type-sub '>Pronouns &#8211; optional<\/label>\n                                                <\/span>\n                        <\/div><div class='gfield_description' id='gfield_description_79_7'>Please write the name of the student who you are filing a report about. If multiple students were involved in one incident, please write their names in the box below.<\/div><\/fieldset><div id=\"field_79_24\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_79_24'><span class='gform-field-label__text'>Additional students involved in the incident (if applicable)<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_24' id='input_79_24' class='textarea medium'  aria-describedby=\"gfield_description_79_24\"    aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><div class='gfield_description' id='gfield_description_79_24'>Please write the additional students&#8217; first (chosen) &#038; last names.<\/div><\/div><div id=\"field_79_9\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_79_9'><span class='gform-field-label__text'>When did the incident\/concern occur? Enter date(s) if applicable, or N\/A.<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_9' id='input_79_9' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_79_10\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_79_10'><span class='gform-field-label__text'>Where did the incident\/concern occur? (e.g., in a specific class or workshop, during a coaching appointment, via email, etc.)<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_10' id='input_79_10' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_79_11\" class=\"gfield gfield--type-multi_choice gfield--type-choice gfield--input-type-checkbox gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Type of Concern (Select ALL that apply)<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_79_11'><div class='gchoice gchoice_79_11_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.1' type='checkbox'  value='Academic Difficulties'  id='choice_79_11_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_79_11_1' id='label_79_11_1' class='gform-field-label gform-field-label--type-inline'>Academic Difficulties<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_79_11_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.2' type='checkbox'  value='Attendance'  id='choice_79_11_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_79_11_2' id='label_79_11_2' class='gform-field-label gform-field-label--type-inline'>Attendance<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_79_11_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.3' type='checkbox'  value='Behaviour\/Disruption'  id='choice_79_11_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_79_11_3' id='label_79_11_3' class='gform-field-label gform-field-label--type-inline'>Behaviour\/Disruption<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_79_11_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.4' type='checkbox'  value='Mental Health\/Emotional Well-Being'  id='choice_79_11_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_79_11_4' id='label_79_11_4' class='gform-field-label gform-field-label--type-inline'>Mental Health\/Emotional Well-Being<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_79_11_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.5' type='checkbox'  value='Accessibility\/Accommodation'  id='choice_79_11_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_79_11_5' id='label_79_11_5' class='gform-field-label gform-field-label--type-inline'>Accessibility\/Accommodation<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_79_11_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.6' type='checkbox'  value='Student Does Not Complete Work\/Disengaged'  id='choice_79_11_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_79_11_6' id='label_79_11_6' class='gform-field-label gform-field-label--type-inline'>Student Does Not Complete Work\/Disengaged<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_79_11_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.7' type='checkbox'  value='Social Skills\/Social Connections'  id='choice_79_11_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_79_11_7' id='label_79_11_7' class='gform-field-label gform-field-label--type-inline'>Social Skills\/Social Connections<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_79_11_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.8' type='checkbox'  value='Other'  id='choice_79_11_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_79_11_8' id='label_79_11_8' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_79_13\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_79_13'><span class='gform-field-label__text'>If you selected Other, please elaborate here.<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_13' id='input_79_13' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_79_14\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_79_14'><span class='gform-field-label__text'>Briefly describe the concern. Focus on the facts (what you saw\/heard and when) rather than speculating.<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_14' id='input_79_14' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_79_15\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_79_15'><span class='gform-field-label__text'>Briefly describe any action you have taken. (e.g., spoke with student privately, suggested Advising appointment, etc.)<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_15' id='input_79_15' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_79_16\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>How urgent is follow-up?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_79_16'>\n\t\t\t<div class='gchoice gchoice_79_16_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_16' type='radio' value='Low (general support, can be monitored)'  id='choice_79_16_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_79_16_0' id='label_79_16_0' class='gform-field-label gform-field-label--type-inline'>Low (general support, can be monitored)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_79_16_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_16' type='radio' value='Medium (needs staff follow-up in 3 or more business days)'  id='choice_79_16_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_79_16_1' id='label_79_16_1' class='gform-field-label gform-field-label--type-inline'>Medium (needs staff follow-up in 3 or more business days)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_79_16_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_16' type='radio' value='High (needs staff follow-up within 1-2 business days)'  id='choice_79_16_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_79_16_2' id='label_79_16_2' class='gform-field-label gform-field-label--type-inline'>High (needs staff follow-up within 1-2 business days)<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_79_17\" class=\"gfield gfield--type-multi_choice gfield--type-choice gfield--input-type-checkbox gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Have you reported this concern\/incident to anyone? (Select ALL that apply.)<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_79_17'><div class='gchoice gchoice_79_17_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.1' type='checkbox'  value='My Coordinator'  id='choice_79_17_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_79_17_1' id='label_79_17_1' class='gform-field-label gform-field-label--type-inline'>My Coordinator<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_79_17_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.2' type='checkbox'  value='My Team\/Squad Leader'  id='choice_79_17_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_79_17_2' id='label_79_17_2' class='gform-field-label gform-field-label--type-inline'>My Team\/Squad Leader<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_79_17_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.3' type='checkbox'  value='ESP Advisor'  id='choice_79_17_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_79_17_3' id='label_79_17_3' class='gform-field-label gform-field-label--type-inline'>ESP Advisor<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_79_17_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.4' type='checkbox'  value='ESP Professor'  id='choice_79_17_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_79_17_4' id='label_79_17_4' class='gform-field-label gform-field-label--type-inline'>ESP Professor<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_79_17_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.5' type='checkbox'  value='I have not reported this to anyone'  id='choice_79_17_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_79_17_5' id='label_79_17_5' class='gform-field-label gform-field-label--type-inline'>I have not reported this to anyone<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_79_18\" class=\"gfield gfield--type-multi_choice gfield--type-choice gfield--input-type-checkbox gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>How is this concern affecting you? (Select ALL that apply.)<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_79_18'><div class='gchoice gchoice_79_18_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.1' type='checkbox'  value='Harder for me to do my job'  id='choice_79_18_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_79_18_1' id='label_79_18_1' class='gform-field-label gform-field-label--type-inline'>Harder for me to do my job<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_79_18_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.2' type='checkbox'  value='Worry\/Stress'  id='choice_79_18_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_79_18_2' id='label_79_18_2' class='gform-field-label gform-field-label--type-inline'>Worry\/Stress<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_79_18_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.3' type='checkbox'  value='Extra Time\/Workload'  id='choice_79_18_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_79_18_3' id='label_79_18_3' class='gform-field-label gform-field-label--type-inline'>Extra Time\/Workload<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_79_18_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.4' type='checkbox'  value='Other'  id='choice_79_18_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_79_18_4' id='label_79_18_4' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_79_19\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_79_19'><span class='gform-field-label__text'>If you selected Other, please elaborate here.<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_19' id='input_79_19' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_79_20\" class=\"gfield gfield--type-multi_choice gfield--type-choice gfield--input-type-checkbox gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>How is this concern affecting other students? (Select ALL that apply.)<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_79_20'><div class='gchoice gchoice_79_20_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.1' type='checkbox'  value='Other students seem uncomfortable'  id='choice_79_20_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_79_20_1' id='label_79_20_1' class='gform-field-label gform-field-label--type-inline'>Other students seem uncomfortable<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_79_20_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.2' type='checkbox'  value='Other students&#039; learning is affected'  id='choice_79_20_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_79_20_2' id='label_79_20_2' class='gform-field-label gform-field-label--type-inline'>Other students&#8217; learning is affected<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_79_20_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.3' type='checkbox'  value='Other students avoid attending classes\/workshops'  id='choice_79_20_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_79_20_3' id='label_79_20_3' class='gform-field-label gform-field-label--type-inline'>Other students avoid attending classes\/workshops<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_79_20_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.4' type='checkbox'  value='Other students are aware of the concern, but don&#039;t seem affected'  id='choice_79_20_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_79_20_4' id='label_79_20_4' class='gform-field-label gform-field-label--type-inline'>Other students are aware of the concern, but don&#8217;t seem affected<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_79_20_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.5' type='checkbox'  value='Other students are not aware of the concern'  id='choice_79_20_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_79_20_5' id='label_79_20_5' class='gform-field-label gform-field-label--type-inline'>Other students are not aware of the concern<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_79_20_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.6' type='checkbox'  value='Other'  id='choice_79_20_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_79_20_6' id='label_79_20_6' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_79_21\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_79_21'><span class='gform-field-label__text'>If you selected Other, please elaborate here.<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_21' id='input_79_21' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_79_22\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_79_22'><span class='gform-field-label__text'>Is there anything else the ESP staff should know?<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_22' id='input_79_22' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_79_23\" class=\"gfield gfield--type-captcha gfield--input-type-captcha field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label 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