Name (optional)

Pronouns (optional)

Student ID

Email Address (optional)

Phone (optional)

Do you wish to remain anonymous? Do you wish to remain anonymous? Yes No

Where did this incident occur? Where did this incident occur? Café Columbia Gym Egan Leadership Center (ELC) Library Off campus Third Street Academic Center (TSAC) Other

If other, where? (limit 100 characters)

To the best of your knowledge, in which academic program, school, college, or department did the incident occur? To the best of your knowledge, in which academic program, school, college, or department did the incident occur? N/A Admissions Advancement Athletics Auerbach School of Occupational Therapy College of Education Marketing Naslund-Mann School of Writing School of Business School of Writing School of Professional Psychology School of Nursing School of Social Work I do not know

In what context did the incident occur? In what context did the incident occur? During class During practicum/internship During a meeting outside of class During an on-campus social event Outside of class Other

If other, please briefly describe or categorize the context. (limit 100 characters)

When did this incident occur?

What behaviors were experienced or witnessed? (please check all that apply) What behaviors were experienced or witnessed? (please check all that apply) Bullying Harassment Physical altercation/fight Threat/Intimidation Vandalism Verbal altercation Other

If other, please briefly describe or categorize the behavior(s). (limit 200 characters)

Did the incident include social media, digital communications, or printed materials? If so, please check all that apply. If not, please leave blank. Did the incident include social media, digital communications, or printed materials? If so, please check all that apply. If not, please leave blank. Email Facebook Flyer/Bulletin Board GroupMe Instagram Note/Letter Phone Call Snapchat Text/SMS/iMessage Twitter Video Meeting/Chat WhatsApp Other

If other, please list what was used. (limit 100 characters)

What was the focus of the behavior? (please check all that apply) What was the focus of the behavior? (please check all that apply) Age Disability Gender Expression Gender Identity Language National Origin Race/Ethnicity Religion Sexual Orientation Socio-Economic Status Veteran Status Other

If other, please briefly describe or categorize the focus of the behavior. (limit 200 characters)

On whose behalf are you filing this report? On whose behalf are you filing this report? Myself Someone else

If filing on behalf of someone else, are they aware you are filing this report? If filing on behalf of someone else, are they aware you are filing this report? Yes No

Following the incident, have you been in contact with anyone involved? Following the incident, have you been in contact with anyone involved? Yes No

Which group does the person/group who engaging in the reported behaviors belong to? Which group does the person/group who engaging in the reported behaviors belong to? Alumni Faculty Practicum/Internship supervisor Staff Student Visitor/Not affiliated with Spalding I do not know

How does this incident impact you? How does this incident impact you? I am directly affected I am indirectly affected I am a witness, but not affected

Which group does the person/group impacted belong to? Which group does the person/group impacted belong to? Alumni Faculty Staff Student Visitor/Not affiliated with Spalding I do not know

What are the details regarding this incident? Things to consider: What happened? What impact has this incident/behavior/action had on those it was directed toward? Is there anyone else who may be impacted? What are the immediate needs? What is most concerning about this incident?