Harassment and Discrimination Reporting Form

Creighton University has an expectation that faculty, staff and students will share information they receive about harassment and discrimination.

Instructions: Fill in all fields that apply.  Report only one incident per form.  Please submit this form to the Office of Equity and Inclusion within 24 hours of becoming aware of any report

This form will be submitted to the Associate Vice-President for Equity and Inclusion.  If you have an immediate assistance, please contact the Department of Public Safety at 402-280-2911

Please enter your contact information below:
Your Name
Net ID
Position/Title
Department
Phone
Email address

This incident was reported by:
Complainant/Victim
Self
Witness
Third-Party
Anonymous

Date report was made (date you learned of the incident)
Date (month, day, year)

When did the incident occur?
Date (month, day, year)
approximate time (am/pm)

Where did the incident occur?
Campus Building
Campus Grounds
Off-campus
Other (please specify) 

Specific location of incident (building name, room number, etc.):
Location:

Please describe the incident in as much detail as possible:

Was a weapon involved in the incident?
Yes (please explain) 
No
Unsure (please explain) 

How many accused individual(s)/respondent(s) are involved in the incident?  (1 person or more?)
Number

What is the role of the accused individual(s)/respondent(s) on campus?
Student
Faculty
Staff
Visitor/Guest
No campus role
Unknown

Please provide the name of the accused individual(s)/respondent(s):
Name

Was there any evidence that this incident was motivated by the complainant/victim's (select all that apply):
Race
Ethnicity
Age
Gender
Sexual Orientation
Religion
Disability
National Origin
Veteran Status

Are there any other departments or individuals to whom the complainant/victim has reported the incident?
Department/individual name

Please provide the name and contact information for the complainant/victim below:
Name
Phone
Email

If there are any relevant witnesses to the incident, please list their name and contact information below:
Name
Phone
Email

If you have additional witnesses, please list their name, phone, and email in the space provided below:


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