Report an Incident

Reporter's Information

Enable additional features by logging in.

Name/Leave blank if Anonymous:

Learn more

Please enter your name. If you wish to remain anonymous, enter Anonymous or leave blank.

Date you learned of incident:

Reporter's email address:

Learn more

A copy of this report will be sent to this address, unless you deselect the option at bottom of form

Who was involved in incident?(Required):

This field is required.

Who is/could be affected?(Required):

This field is required.

Learn more

Please select from the dropdown menu

Date of incident(Required):

This field is required.

Learn more

If you don't recall date or there are multiple dates, enter date behavior started/became concerning

Time of incident:

What is your primary concern(Required):

This field is required.

Learn more

While you may have multiple concerns, please select the one that best describes your primary concern

Involved Individuals, Organizations or Groups

Please list the individuals, organizations and/or groups involved in this incident, including as many of the listed fields as you can provide.

Name of Individual or Organization

Affiliation to Cornell

Role

Phone Number

Email Address

Please provide information about your experience and/or observations.

For a list of campus resources, including confidential contacts, visit: https://mentalhealth.cornell.edu

Where did this incident take place? If the behaviors occurred in more than one location, please select the location where the conduct began and provide further details about additional locations in the space provided for the description of the incident.(Required) This field is required.

Please provide street address or specific location on premises, if available. This field is required.

Please provide a description of the incident using concise and objective language. If you have a desired outcome, please include details here.(Required) This field is required.

Please describe the atmosphere prior to the incident and the impact that this incident may have on the learning and/or workplace environment. If you do not feel there is an impact to the learning and/or workplace environment, you may leave this blank. This field is required.

Please provide the police report number, if applicable and available. if the police were involved but you do not know the report number, please enter 'police involved but I do not know the report number.' If the police were not involved, please enter N/A, in the space below. This field is required.

If you have been designated as a Cornell University Campus Security Authority (CSA) as defined by the Clery Act, and are reporting a Clery reportable crime or incident, please select the category that you determine to be appropriate. To access information about CSA's responsibiities, Clery crime definitions and Clery geography, please see: https://www.cupolice.cornell.edu/campus-watch/ This field is required.

Please remember that the timing and manner in which the University addresses this report will vary depending on the information provided and whether involved parties are available for further discussion.

You may contact me To the extent possible, I would like to remain anonymous to involved individuals, but you may contact me Please do not contact me

This field is required.

Please list your phone number or email address, in the event that we need to contact you. If you have filed this report anonymously or do not want to be contacted, please enter "do not contact me" in the space below.(Required) This field is required.

Supporting Documentation

PLEASE ATTACH SUPPORTING TEMPLATES AND DOCUMENTS

(Examples may include: photos, emails or video clips)

5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

Email me a copy of this report

Reporter's Information

Involved Individuals, Organizations or Groups

Please provide information about your experience and/or observations.

Supporting Documentation

Submission