Harassment, Discrimination, and Retaliation Incident Report

Background Information

Please fill out as much information as possible.

Your full name:

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Your position/title (if any):

Your phone number:

Your email address:

Email address must be of a valid format.

Type of complaint(Required):

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Date of incident:(Required):

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If you do not know the actual date of the incident, please use the date it was reported to you.

Time of incident (if known):

Location of incident:(Required):

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Specific location (if known):

Involved Parties

Please provide the names and roles of individuals or organizations involved in the incident. Please complete as much of the other requested information as possible. Click the button labeled Add Another to include more people.

Name

Role

Student PID # or Employee ID#

DOB (YYYY-MM-DD)

Phone number

Email address

Campus or Local Address

Questions

Supporting Documentation

You may upload supporting documentation in .pdf format. This could include photos, text messages, emails, etc. Please convert text files to .pdfs before uploading. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

Background Information

Involved Parties

Questions

Supporting Documentation

Submission