Items marked with a diamond
♦ are required fields.
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”.)
Indicate the office/individual you communicated with.
Campus, School, Department, & Area
Select Campus 1st
Clinical Rotation, on campus
Clubs on campus
University sponsored event/program
(Select One; Provide any additional specifics in the "Location/Address" field below.)
Exact Address, at the Library, etc.
In the lab, certain classroom, etc.
Off campus address, location or function
Identification & Contact Information
(Including but not limited to the responsible parties, victims, witnesses, and/or others.)
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
firstname.lastname@example.org or 617-627-3298.
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
Follow-up will allow you to:
Response to follow-up questions
Provide additional information