General Concern Report

Background Information

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Your full name:

Your position/title:

Your phone number:

Your email address:

Email address must be of a valid format.

Your physical address:

Nature of this report(Required):

This field is required.

Date of incident(Required):

This field is required.

Time of incident:

Location of incident(Required):

This field is required.

Specific location:

Involved Parties

Please enter the individual(s) involved below excluding yourself. Be sure to include a UNI (in all lower-case), if it is known.

For student organization(s) and/or group(s), please enter the organization name with no spaces in the UNI field. (Example: "Alpha Beta" would be entered as "alphabeta")

For non-students, please list a ID type and number or Drivers License number in the UNI field if available. (Example: NYS DL # 86-753-09)

Name or Organization

Select Role

UNI (all lowercase)

DOB (YYYY-MM-DD)

Phone number

Email address

Hall/Room

Details of Concern

Please provide a detailed description of the incident/concern using specific concise, objective language (Who, what, where, when, why, and how). This field is required.

Does this student have a basic needs concern? Please select all that apply.

Food Housing Clothing Financial Other- Please elaborate above

You must make at least one selection.

Supporting Documentation

Photos, video, email, and other supporting documents may be attached below. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

General Concern Report

Background Information

Involved Parties

Details of Concern

Supporting Documentation

Student Affiliation(s)

Submission