Incident Details

	Add Issue Add Issue

Incident Description	♦ Provide as much detail as possible regarding this incident/concern. (WHO, WHAT, WHERE, and WHEN, if known) ♦ Date/Time of the incident/concern. (Ex: “Monday, April 2nd in the afternoon; the week of May 23rd ; sometime in May of this year”.)

Previously Reported	♦ Have you previously reported this incident to a Tufts University employee (i.e., Faculty, Manager/Supervisor, Residential life, Campus Police or other?) Yes No (Select One) ♦ Indicate the office/individual you communicated with.

Incident Location

Campus, School, Department, & Area	♦ Campus (Select One) ♦ School (Select One) Department ♦ Specific Area/Event (Select One; Provide any additional specifics in the "Location/Address" field below.) ♦ Did this incident occur on the Tufts University Campus/Location? Yes No (Select One)

Physical Location	♦ Location/Address Examples: Exact Address, at the Library, etc. In the lab, certain classroom, etc. Off campus address, location or function City ♦ Country

Identification & Contact Information

Identity	♦ Do you wish to provide your name and contact information? (Please note that by choosing not to identify yourself; it may limit the University's ability to address this matter.) Yes No (Select One)

Name & Contact Information	♦ Relationship to the University (Select One) ♦ “Other” Relationship ♦ First Name ♦ Last Name ♦ Preferred method of contact. Phone Email (Select One) Phone Number (Preferred) Include the area code, extension, and/or dialing codes if applicable. Phone Number (Alternative) Include the area code, extension, and/or dialing codes if applicable. Email (Format: username@domain.com)

Name & Contact Information

♦

Relationship to the University

(Select One)

♦

“Other” Relationship

♦

First Name

♦

Last Name

♦

Preferred method of contact.

Phone Email

(Select One)

Phone Number (Preferred)

Include the area code, extension,
and/or dialing codes if applicable.

Phone Number (Alternative)

Include the area code, extension,
and/or dialing codes if applicable.

Email

(Format: username@domain.com)

Role	♦ Do you consider yourself a victim in regards to this incident/concern? Yes No (Select One) ♦ What is your relationship to the victim? Does the victim know you are reporting? Yes No Unsure (Select One)

Participants (Including but not limited to the responsible parties, victims, witnesses, and/or others.)

Participants	♦ Were any “Participants” involved in this incident? Yes No (Select One)

Acknowledgements

Acknowledgement	Acknowledgement I acknowledge that the information I provided in this report is accurate and truthful to the best of my knowledge and I will not engage in retaliation of any kind.

Non-Retaliation Statement	Any member of the Tufts University community has the right to raise concerns or make a complaint regarding discrimination, harassment, or sexual misconduct without fear of retaliation. It is a violation of Tufts University policy to retaliate against an individual for filing a complaint of discrimination, harassment and/or sexual misconduct or cooperating in an investigation of alleged discrimination, harassment and/or sexual misconduct. Any person at Tufts University found in violation of this policy is subject to disciplinary action up to and including termination of employment or expulsion from school. If you have any questions or concerns about this non-retaliation statement please contact Jill Zellmer, Director of the Office of Equal Opportunity by email at jill.zellmer@tufts.edu or 617-627-3298.

Non-Retaliation Statement

Any member of the Tufts University community has the right to raise concerns or make a complaint regarding discrimination, harassment, or sexual misconduct without fear of retaliation.

It is a violation of Tufts University policy to retaliate against an individual for filing a complaint of discrimination, harassment and/or sexual misconduct or cooperating in an investigation of alleged discrimination, harassment and/or sexual misconduct. Any person at Tufts University found in violation of this policy is subject to disciplinary action up to and including termination of employment or expulsion from school.

If you have any questions or concerns about this non-retaliation statement please contact Jill Zellmer, Director of the Office of Equal Opportunity by email at jill.zellmer@tufts.edu or 617-627-3298.

Password

Password	♦Password ♦ Re-Enter Password (Passwords must be at least four(4) characters in length.)

Submit	Please allow 48 hours for Tufts University to review and respond to your incident. If you feel this issue requires more immediate action please contact TUPD at 617-627-6911 or x66911 When you submit this report, you will be issued a Report Key. Please write this information down along with your password, in a secure and private place. Neither your report key, nor your password, can be recovered, or reset once this report has been submitted. Using your Report Key and Password you can "Follow-Up" on this report by logging into tuftshelpline.ethicspoint.com Follow-up will allow you to: Upload documents Response to follow-up questions Provide additional information

Submit

Please allow 48 hours for Tufts University to review and respond to your incident. If you feel this issue requires more immediate action please contact TUPD at 617-627-6911 or x66911

When you submit this report, you will be issued a Report Key. Please write this information down along with your password, in a secure and private place. Neither your report key, nor your password, can be recovered, or reset once this report has been submitted.

Using your Report Key and Password you can "Follow-Up" on this report by logging into tuftshelpline.ethicspoint.com

Follow-up will allow you to:

Upload documents
Response to follow-up questions
Provide additional information

Incident Report Form

Office of Equal Opportunity

This is NOT a 911 or Emergency Service