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Incident Report Form

    IF THIS IS AN EMERGENCY, please call security (Ext. 5555) or 911

    Please complete as much information as possible. The timing and manner in which the Lab response to this report will vary depending on the information provided and whether you wish to remain anonymous.

    This form can be used to report an incident involving an alleged violation of:

    • Equal Opportunity Policy - Policy prohibiting discrimination, harassment, and retaliation in the workplace, and setting forth the Laboratory's procedures for handling complaints relating to alleged discrimination, harassment, and retaliation.

    • Title IX Policy And Procedures For Allegations Of Sex Discrimination, Sex-Based Harassment, And Retaliation - Title IX of the federal Higher Education law prohibits discrimination on the basis of sex in any education program or activity receiving federal assistance.

    • Whistleblower Policy - Policy outlining reporting procedures and protections available to Laboratoryemployees (current or former), independent contractors, volunteers and students who seek to report workplace activities reasonably considered to be illegal or dishonest.

    * indicates a required field

    Your Information

    Date and Approximate Time of Incident: *

    Involved Parties

    Incident Information

    Depending on the nature of an alleged incident, Laboratorymay be required to take action based on information contained in a report. In the course of an investigation, information will be shared as necessary with people who need to know, such as investigators, witnesses, and the respondent. Any response by Laboratorymay be hindered by the complainant's request for anonymity and/or inaction.

    * What type of resolution/next steps are you seeking by submitting this report?

    * Please know that, depending on the nature of an alleged incident, a student who files a report may or may not be able to fully participate in a process or become aware of a resolution. With this in mind, to what level of involvement are you seeking in an investigation or resolution?

    Supporting Documentation (optional)

    Photos, video, email, and other supporting documents may be attached below. Maximum 12 megabytes per file.
    Attachments require time to upload, so please be patient after you click to submit this report.
    If you wish to submit additional documentation, please do so here. (protected by reCAPTCHA)

    * indicates a required field