Reporting Form

Background Information

While we don't require your name, in responding to these incidents, it is often very helpful to have the identity of the individual making the referral so we can follow-up most appropriately and make sure you are also supported.

Residential Life staff members must complete all questions. Please note that students have the right to request a copy of any forms submitted on their behalf.

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Reporter Full Name:

Reporter's UVM Affiliation:

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Student, Staff, Faculty, RA, Relative

Reporter Phone Number:

Reporter Email Address:

Email address must be of a valid format.

Reporter Physical Address:

Nature of this Report(Required):

This field is required.

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Please indicate the category your concern falls into.

Urgency 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:

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Add an on campus or off campus address, if applicable.

Involved Parties

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

Name or Organization

UVM Affiliation

ID Number

DOB (YYYY-MM-DD)

Phone Number

Email Address

Hall/Address

Questions

Please answer the following questions so that we can best respond to you and the person(s) involved.

Were UVM Police or other emergency services called?(Required)

Burlington Police Department University of Vermont Police Department University of Vermont Rescue Other

You must make at least one selection.

Was this reported to anyone other than using this form? (Yes/No) (If Yes, tell us who.)(Required) This field is required.

Please list any names and contact for any witnesses. This field is required.

Does this incident appear to be bias related? (Yes/No) (If Yes, please explain what constitutes a bias event and give any related details.) This field is required.

Did this incident result in theft, property damage, or monetary loss? (Yes/No) (If Yes, please indicate what was stolen or damaged, and the estimated amount of loss. This field is required.

Supporting Documentation

Please attach any documentation, pictures, or other files in PDF format. 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

Questions

Supporting Documentation

Submission