This form is being used by UMHS to empower victims and bystanders to identify and report acts of discrimination, harassment, intimidation and bullying. All reports will remain confidential, but please be aware that administration can only act if they have enough information to do so. Please record on this form as many details and witness names as possible.
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Reporter's Name:
Name of Victim(s):
Name of Aggressor(s): *
Name of Witnesses: *
Date of incident: *
Approximate time of incident: *
Location of incident: *
Detailed description of mistreatment: *
Provide any background information that may be helpful to this investigation: *
Are there any emails, webpages, snap chats, Instagram posts, etc. that would be helpful for this investigation? Please explain: *
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