Report a Concern or Violation

Background Information

Thank you for taking the time to share your concerns regarding an individual at The University of Southern Mississippi. By sharing your concerns, you are helping to maintain a healthy and safe campus environment at USM.

Your full name:

Your position/title:

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Faculty/Staff, Student, Mental Health Clinician, Other

Your phone number:

Your email address:

Email address must be of a valid format.

Nature of this report(Required):

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Select

Urgency of this report(Required):

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Date of incident(Required):

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Time of incident:

Location of incident(Required):

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Student of Concern or Involved Parties

Please list the individuals involved (excluding yourself), including as many of the listed fields you can provide.

Name or Organization

Select Gender

ID Number (without W)

Phone number

Email address

Questions

Please provide a detailed description of the incident/concern using specific concise, objective language (who, what, where, when, and how). The use of direct quotes is encouraged, including profanity or abusive language that may have been used during the incident. This report will be submitted to the Dean of Students Office and, if necessary, the appropriate Residential Area for review. Please also include the student's preferred pronouns, if known. This helps us respectfully address the student when responding to reports.(Required) This field is required.

Was EMS involved in the incident?(Required) This field is required.

Were any of the following police agencies involved?(Required) This field is required.

If "other" was selected, please indicate the police agency involved: This field is required.

If this incident occurred in a residence hall, please select the hall below:(Required) This field is required.

I understand that referrals from this form will be received during normal University business hours and are not monitored after hours, on weekends, or during official University holidays/closings. Please contact the University Police Department at (601) 266-4986, if there is an immediate risk of harm to self or others prior to submitting this form.(Required)

I understand

This field is required.

Supporting Documentation

Please provide any documentation that can help us have better understanding of the situation. This can include text messages, e-mails, voicemails, videos, reports, etc. 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

Student of Concern or Involved Parties

Questions

Supporting Documentation

Submission