Discrimination - Harassment Reporting Form

Background Information

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Your full name:

Status (Student,Employee,etc):

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Are you a Student, Applicant for School, Applicant for Employment, Employee, or Other

Your phone number:

Your email address:

Email address must be of a valid format.

Gender, Race/Ethnicity:

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

Name or Organization

Gender

Role

ID Number

DOB (YYYY-MM-DD)

Phone number

Email address

Hall/Address

Description of Incident

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.

Email me a copy of this report

Background Information

Involved Parties

Description of Incident

Supporting Documentation

Submission