COVID Public Health Behavior Report Form

Background Information

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Your full name:

Your phone number:

Your email address:

I am reporting about a...(Required):

This field is required.

Date of incident(Required):

This field is required.

Time of incident:

Location of incident(Required):

This field is required.

Specific location:

Involved Parties

Please complete the fields below to the best of your ability. In many situations you may not have access to some of the information. When choosing the parties role in the incident; an "alleged" is someone whose behavior you believe violates the University's expectations for observing public health precautions; a "victim" is someone who might have been verbally or physically harmed by another person's behavior; and a "witness" is someone who observed the reported behavior.

Name

University Affiliation

Role in the Incident

CSUID Number

Incident Description

Please provide a detailed description of the incident/concern using specific, concise and objective language. Include all relevant information, including who was involved in the incident, when and where it took place, and what happened during the incident.

Narrative:(Required) This field is required.

Supporting Documentation

Photos, video, email, and other supporting documents may be attached below. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

Background Information

Involved Parties

Incident Description

Supporting Documentation

Submission