Student Misconduct Incident Report Form

Background Information

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Your full name:

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Or, you may write Anonymous

Your position/title:

Your phone number:

Your email address:

Email address must be of a valid format.

UIN:

Nature of this report(Required):

This field is required.

Urgency of this report(Required):

This field is required.

Date of incident(Required):

This field is required.

Time of incident:

Location of incident(Required):

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Specific location:

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Example: Room 311

Involved Parties

Please list the individuals involved (excluding yourself), including as many of the listed fields as you can provide.

Name or Organization

Select Gender

Select Role

UIN

DOB (YYYY-MM-DD)

Phone number

Email address

Hall/Address

Questions

Please provide a detailed description of the incident/concern using specific concise, objective language (Who, what, where, when, why, and how).

What happened? Please describe, in great detail, the concern, incident, and/or behavior(s) that you observed.(Required) This field is required.

What were the impacts of the behavior or incident? How were others affected? This field is required.

Have you addressed your concern(s) with the individual(s) or Registered Student Organization (RSO)? If so, please describe the conversation(s) and outcome(s).(Required) This field is required.

Please list any other University community members (e.g., faculty, staff, and students), departments, or outside agencies that were contacted about the concerns you have shared This field is required.

What is the resolution or set of resolutions you are seeking as a result of submitting this report?(Required) This field is required.

I understand that this report will only be reviewed during normal business hours, Monday - Friday 9:00 AM to 5:00 PM, and are not monitored after hours, on weekends, or during official University holidays. If I believe there is an immediate risk of harm to self or others, I will contact UICPD at (312) 355-5555 prior to submitting this report.(Required)

Yes, I understand

You must make at least one selection.

Is there anything else you would like to add? This field is required.

Supporting Documentation

Attach additional documents or supporting materials (e.g., Emails, screenshots, text messages, audio recordings, pictures, photographs, videos, etc.) that supplement your narrative 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

Email me a copy of this report

Background Information

Involved Parties

Questions

Supporting Documentation

Submission