MUS Incident Report Form

Name (optional)

Email (optional)

Phone (optional)

Date of incident (optional)

MonthDayYear

Location of incident (off campus, at an MUS event, in class, etc). Feel free to be as specific as you would prefer.*

Description of Incident: Please describe the incident in as much detail as you feel comfortable disclosing to us. You may choose to disclose the names of the individuals involved as well as their roles in the incident.*

How would you like us to respond to your situation?*

ANONYMOUSNON - ANONYMOUSI would like to have a follow up but do not wish to reveal my identity. The Ethics Board will set up an email account which will remain confidential. Use the code to create a gmail account (For instance, if the code is h9ocr34j - create the email account h9ocr34j@gmail.com). Enter Ethics Board as you first name and Petitioner as your last name. The Ethics Board will contact you using this email account and your identity will never be revealed. You must set up this account before submitting this form as the code will not be available after you submit.Other

I would like the Ethics Board to

Take action, including investigating to the fullest extent possible the incident. The Ethics Board will contact me to further discuss this.Take action, but please do not contact me or ask me to produce more than the information I submitted hereTake note of the incident, but do not start any form of investigation. I am only filling out this form such that the Ethics Board becomes aware of the incident.Other

Thank you for reporting your incident. If you entered your name and contact info, we will be contacting you within 24 hours to follow up on this situation.Thank you for reporting your incident. If you entered your name and contact info, we will be contacting you within 24 hours to follow up on this situation.