Informal Complaint

Information about you

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Your full name:

Your role at the University:

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Examples: student, staff, faculty, other employee, visitor, not affiliated with the University

Your phone number:

Your email address:

Email address must be of a valid format.

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(If you have a purdue.edu email address, please provide that here.

Your physical address:

Date of incident(Required):

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Date of incident or most recent incident

Time of incident:

Where did the incident occur?(Required):

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Specific location:

Information about Respondent(s)

Please provide the following information about the person(s)/organization you are complaining about.

Full Name or Name of Organization

Select Gender

Role at the University

PUID Number

DOB (YYYY-MM-DD)

Phone number

Email address

Hall/Address

Information about the Incident and Desired Resolution

Please provide a brief description of your complaint in your own words. Please answer who, what, why, where, when, how, etc. and be specific. If you need additional space, please upload an attachment.(Required) This field is required.

What is your desired outcome or proposed resolution?(Required) This field is required.

Have you reported this complaint to any other University department? Police? State or Federal Agency?(Required)

Yes No

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If you answered “yes” to the previous question, please state the name of the agency or University department and the date you reported.(Required) This field is required.

By entering my initials below, I certify that the information I have provided here is true and accurate to the best of my knowledge and belief.(Required) This field is required.

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

Information about you

Information about Respondent(s)

Information about the Incident and Desired Resolution

Supporting Documentation

Submission