Background Information

Your First Name:

Your Last Name:

Your Phone Number:
(###-###-####)

Your Email Address:

Date of Incident:

Time of Incident:

Location of Incident:

Specific Location:

Involved Parties

Please list the individuals involved (excluding yourself). Including as many of the listed fields as you can provide. For non-students, please list a Drivers License number, if known, in the block labeled ID Number (student ID #). Do not use Social Security Numbers for the ID Number.
(Click the Add Person button after entering each party's data to add the person to the form)

Name:

Gender:

Incident Role:

ID Number:

Phone Number:
(###-###-####)

Email Address:

Questions

Please provide a detailed description of the incident/concern using specific, concise, objective language. A properly submitted Reporting Form will include:

1. Date, time and location of the incident
2. Who confronted the situation and why
3. Everyone listed as being involved in the report must be identified in the narrative at some point indicating their involvement or lack thereof
4. State what factually occurred

Did you take any action to stop the harassment? If yes, please summarize.

Was 911 notified?

Do you want this complaint to be investigated?

Supporting Documentation

Photos, video, e-mail, and other supporting documents may be attached below. Attachment may require time to upload, please be patient after submitting this form (more than one document may be uploaded).

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