Qualtrics Survey | Qualtrics Experience Management

Location of incident/event/behavior

Date of incident

Date of incident<div><br></div><div><br></div>
	Month	Day	Year



Please Select:	Month - Please Select:	Day - Please Select:	Year - Please Select:

If known, please provide the name of the organization/group involved.

If you do not know the name of the organization/group involved, did you observe anything that could help us identify the organization (dressing in similar clothing, letters on house or clothing, insignia, items in their possession, etc.)?

Please provide a detailed description of the incident/event/behavior.

Please provide all the details you can. To aid our ability to investigate the report, err on the side of providing more detail, not less.

Example: “While walking leaving campus, I observed a group of young men marching down Middle Path chanting in a line. I counted eleven men and they were all dressed the same, in white t-shirts and blue jeans. It was snowing and none of the men were wearing coats. Several men in wearing coats were yelling things at the men lined up. I heard profanities and obscenities. I heard one person yell, “You (expletive deleted) pledges aren’t getting in until you recite it right”

Another example: "Most of the individuals standing outside had red books in their right hands. I overheard one of the individuals standing outside say, “This is stupid” as I walked by. I observed the individuals standing there from 11:56 p.m. to 12:08 a.m. Most of them had their arms folded in front of them as if to keep warm”

How did you become aware of this event/behavior (ex: I observed it myself, I heard about it from a third party, saw it on social media, etc.)?

If you know the names of any individuals involved with, or aware of, this behavior/incident, please provide them.

Please provide any additional information about the incident/event/behavior (ex: If you know, how long has this activity been occurring? Is this activity a tradition?)

Please upload any picture or screenshots you have that may be helpful in the investigation

Your name (optional--please consider providing your name--we will not identify you as the source of the information to the suspected parties, but doing so allows us to contact you with important follow-up questions that will aid our investigation and response and/or to provide you with updates).

Your phone number (providing a phone number allows us to contact you with follow-up questions or updates). You do not need to identify yourself if you choose to provide a phone contact.

Your email address (providing an email allows us to contact you with follow-up questions or updates). If you wish to remain anonymous, you can create an email account on Gmail or a similar mail host to preserve your anonymity.