Incident Reporting Form

Background Information

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Your full name:

Your phone number:

Your email address:

Email address must be of a valid format.

Date of incident(Required):

This field is required.

Time of incident:

Location of incident(Required):

This field is required.

Specific location:

Involved Parties

Name or Organization

Select Role

ID Number

Phone number

Email address

Questions

Please explain the situation in detail including: Who, What, When, Where, Why, & How?(Required) This field is required.

Were emergency services called?(Required)

yes no

This field is required.

If this is Campus Climate related, please indicate the type of bias below. This field is required.

I am a student, staff, or faculty member at the University of Minnesota Duluth.(Required)

Yes No

This field is required.

I am willing to attend a formal hearing on this matter if scheduled.(Required)

Yes No

This field is required.

I understand that the accused will have access to your complaint.(Required)

Yes

This field is required.

All of the information I provide will be accurate to the best of my knowledge.(Required)

Yes

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

Background Information

Involved Parties

Questions

Supporting Documentation

Submission