Online Campus Incident Report

The Multicultural Center has done everything possible to ensure the security and confidentiality of this report. This report is safe! No one but the director of the Multicultural Center will receive it. However, for your own peace of mind we encourage you to visit the Multicultural Center to complete a form in person. For any questions regarding these reports please contact Don Brown, the director of the Multicultural Center.

Fields marked with an asterisk (*) are mandatory


 
Optional & Confidential
First Name:
Last Name:
Please enter your room or office (Building & Number):
Please enter your telephone number (If you have a room or office on campus just leave your voicemail ext.):
 
Required Information
*Today's Date: (mm/dd/yy)
*Date of Incident:
*Time of Incident:
*Location of Incident:
*Campus:
*Type of Incident:
 Graffiti
Verbal attack
Vandalism
Poster
Physical attack
Harassment
Other, Please specify
*Category of Intolerance:
 Disability
Religion
Ethnicity
Sexual Orientation
Gender
Marital Status
Race
Other, Please specify
*Please give a detailed description of the incident. You have unlimited space.
 
Information about person(s) involved, if known:
Name:
Address:
Gender:
Race:
College Status:
Role in Incident:
Name:
Address:
Gender:
Race:
College Status:
Role in Incident:
Have any actions already been taken, i.e. have you contacted any one else?
 Yes
No
If you answered yes, please explain:

When you are satisfied, please click

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