Use for this report: Choose one... For information only For action

Date of incident: - -
Time : AM PM

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: 

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 Other (please specify) If other:

The incident was (check all that apply): 

verbal (phone or in person)

property damage

written

other (please specify):

physical

pursuit or stalking

threat

Additional information about the incident: 

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:

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 (please specify)   If other, please specify:

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 or faculty person other (please specify)   If other:

To your knowledge, was this 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?

Were you satisfied with the response/action? Choose one... Yes No Unsure Not applicable

Why or why not (if applicable)?

Was this incident reported to any campus agency or department? Choose one... Yes No Unsure

If not, what were the reasons for not reporting?

If yes, to which agency/department was it reported?

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)?

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: