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USE FOR THIS REPORT:

How will my information be used? 

1. DATE OF INCIDENT: - -

 

2. TIME :   

 

3. LOCATION OF INCIDENT:
  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.

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.

  IF OTHER, PLEASE SPECIFY:

                  

8. THE PERSON COMPLETING THIS FORM IS THE:   

IF OTHER, PLEASE SPECIFY:


9a. WAS THE INCIDENT REPORTED TO A POLICE AGENCY?   

IF NOT, WHAT WERE THE REASONS FOR NOT REPORTING?

IF YES, WHAT WAS THE RESPONSE/ACTION?

b. WERE YOU SATISFIED WITH THE RESPONSE/ACTION?

WHY OR WHY NOT? (IF APPLICABLE):



10a. WAS THE INCIDENT SHARED WITH OR REPORTED TO ANY CAMPUS AGENCY OR DEPARTMENT?

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?

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:  

 

 

          

 

University of New Hampshire
Affirmative Action and Equity Office
Thompson Hall 305, 105 Main Street, Durham, NH 03824-3547
603-862-2930 voice/tty . 603-862-2936 fax
affirmaction.equity@unh.edu