Items marked with a red diamond are required fields.

Incident Details

 
What
(Select One)
If you feel the incident involves more than one of these issues, please choose the one most significant in your eyes and list the other issue(s) in your detailed description of the incident, below.
 
Description:

(No Issue Selected)
 
 
(Select One)
If you feel that multiple types of bias were involved, please select the one most significant in your eyes and list the other type(s) of bias in your detailed description of the incident, below
 
 
 
 
Where did the incident take place; Campus, Area, Location.
Where 
(Select One)
 
 
(Select One)
 
 
(Specific location, such as building name, address or cross-street.)
Examples:
  • Next to the dumpster, next to the field house.
  • In the lab, storage room.
  • Main Campus library third floor woman's restroom.
 
When
(Ex: Monday, May 24th in the evening; the week of May 23rd; sometime in April 2010.)

If you don't know the exact date & time, please provide an approximate timeframe or specify 'not sure'.
 
 
(Select One)
 
(Select One)
 
 
Have you previously reported this incident to the campus police or another University official?
Previously Reported
(Select One)
   

Your Information

 
Although you can choose to report anonymously, more information may be needed in order to respond appropriately to this incident.
  • If you provide your contact information, your identity will be kept confidential to the extent possible under law.
  • If you remain anonymous, please check back on your report periodically to see if the University has any follow-up questions for you.
 
Do you wish to remain anonymous?
Anonymity
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Relationship
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We collect the following information so that we can identify populations that are/are not likely to report incidents. We want to improve the reporting process to be inclusive for all.
This information is optional, and has no bearing on whether or not we address the issue you're reporting.
Demographics
 
(Select One)
 
 
(Select One)
 
 
(Select One)
 
 
(Select One)
 
 
(Select One)
 
 
(Select One)
   

Participants

 
How would you describe your relationship to the person you presume is primarily responsible?
This person is my ____________(so that we may understand the relationship between the reporter and the alleged person responsible).
Relationship to Participant
 
(Select One)
 
 
 
 
Do you know the identity of anyone involved in this incident (e.g. perpetrator, target, witnesses, accomplices, etc.)?
Involved Parties
(Select One)

Acknowledgement and Submission

 
Acknowledgement
Acknowledge
 
Password

(Passwords must be at least four(4) characters in length.)

Submit
When you submit this report, you will be issued a Report Key. Please write this information down along with your password, in a secure and private place. Neither your report key, nor your password, can be recovered, or reset once this report has been submitted.

Using the system generated report key and password, you may return to this form at any time to submit additional information, provide updates or review your submission.