USE FOR THIS REPORT: Choose one... for information only for action

How will my information be used? 

1. DATE OF INCIDENT: - -

2. TIME : AM PM   

3. LOCATION OF INCIDENT:
Choose one... residence hall on-campus apartment classroom MUB fraternity/sorority other   IF OTHER, PLEASE SPECIFY:

PLEASE GIVE NAME/DETAILED LOCATION IF POSSIBLE: 

4. WHO IS EXPERIENCING THE INTIMIDATION, HARASSMENT, AND/OR DISCRIMINATION?
PLEASE CHOOSE FROM THE OPTIONS PROVIDED OR FILL IN THE BLANK WHERE APPROPRIATE.

Person or group... an individual person a group of people there is no specific person or group of people

UNH Affiliation... UNH student UNH faculty UNH staff UNH volunteer other IF OTHER, PLEASE SPECIFY:

5. THE INCIDENT WAS (CHECK ALL THAT APPLY): 

verbal

property damage

phone

personal

in person

university

written

other (please specify):

online

in person

physical

pursuit or stalking

threat

ADDITIONAL INFORMATION ABOUT THE INCIDENT: 

6. I FELT THE DISCRIMINATION/INTIMIDATION/HARASSMENT WAS BECAUSE OF (CHECK ALL THAT APPLY):

race

age

national origin

color

disability

sexual orientation

religion

veteran status

gender identity/expression

sex

marital status

other (please specify):

7. WHO IS PERPETRATING THE INTIMIDATION, HARASSMENT, AND/OR DISCRIMINATION?

PLEASE CHOOSE FROM THE OPTIONS PROVIDED OR FILL IN THE BLANK WHERE APPROPRIATE.

Choose one... UNH student UNH faculty member UNH staff member parent of student volunteer other   IF OTHER, PLEASE SPECIFY:

8. THE PERSON COMPLETING THIS FORM IS THE: Choose one... subject of behavior witness to the incident friend of the subject partner of the subject staff person faculty person other   

IF OTHER, PLEASE SPECIFY:

9a. WAS THE INCIDENT REPORTED TO A POLICE AGENCY?  Choose one... yes no unsure  

IF NOT, WHAT WERE THE REASONS FOR NOT REPORTING?

IF YES, WHAT WAS THE RESPONSE/ACTION?

b. WERE YOU SATISFIED WITH THE RESPONSE/ACTION? Choose one... yes no unsure not applicable

WHY OR WHY NOT? (IF APPLICABLE):

10a. WAS THE INCIDENT SHARED WITH OR REPORTED TO ANY CAMPUS AGENCY OR DEPARTMENT? Choose one... yes no unsure

IF YES, TO WHICH AGENCY/DEPARTMENT WAS IT REPORTED?
Office of Multicultural Student Affairs (OMSA)
Residential Life
Sexual Harassment and Rape Prevention Program (SHARPP)
Counseling Center
Office of Conduct and Mediation (OCM)
Disability Services for Students (DSS)
Diversity Support Coalition (DSC)
UNH Police Department
Health Services
Human Resources
Department Chair and/or Dean's Office (please specify): 
other (please specify): 

IF NOT, WHAT WERE THE REASONS FOR NOT SHARING OR REPORTING?

b. WHAT WAS THE AGENCY/DEPARTMENT RESPONSE/ACTION?

WERE YOU SATISFIED WITH THE RESPONSE/ACTION? Choose one... yes no unsure not applicable

WHY OR WHY NOT (IF APPLICABLE)?

11. WHAT FURTHER RESPONSE/ACTION WOULD YOU LIKE TO SEE?

CONTACT ME: Yes No, keep this anonymous

Optional Information

You may choose to state your name or to remain anonymous. If you would like to state your name, someone can contact you to follow up on your complaint and offer assistance.

First Name:  

Last Name:  

Phone Number:  

Email Address:  

If there is another way you prefer  
to be contacted, please indicate that here: