Incident Reporting - Incident Form

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Incident Reporting Form

This form is to be used to report incidents of concern to UCLA Extension officials. Please note that there are specific grounds under which an Incident Report may lead to a formal investigation.

All submissions are private. Anonymous complaints may limit our ability to respond. To make an anonymous Sexual Violence and Sexual Harassment (SVSH)/Title IX complaint, please stop filling out this form and contact the UCLA Title IX Coordinator: https://equity.ucla.edu/about-us/our-teams/civil-rights-office/

* All fields marked with an asterisk are required.

Incident Category (please choose primary category) *

(Click for Category Descriptions)

Information – about Incident Categories

Student Conduct: Alleged violation(s) of any provision of the student conduct code
Health/Safety: Behavioral or physical health concerns not related to student conduct code violations
Staff/Instructor Conduct: Complaints against Extension employees, other than discrimination
Sexual Misconduct (Title IX): Gender-based discrimination or harassment, including differential treatment, sexual violence, sexual harassment, domestic violence, intimate partner violence, and stalking
Academic Integrity: Alleged violation(s) of the academic dishonesty policy , including cheating, plagiarism, fabrication, multiple submissions, and research misconduct
Discrimination: Differential treatment based on a person’s federally protected status (e.g. age, race, disability, color, national origin, religion or creed, genetic information, marital status, veteran status, and citizenship) that is so severe and/or pervasive that it limits the person’s ability to participate in the University’s programs or services

Complainant Information

Your affiliation with Extension *

Your Name (skip if you wish to remain anonymous)

Email Address (skip if you wish to remain anonymous)

Phone Number (skip if you wish to remain anonymous)

Incident Details

Please complete the following questions to the best of your ability, to the degree they apply. This will help us properly route your complaint. If the question does not apply, or you do not know the answer, you may skip ahead to the incident description.

Please complete the following section about the RESPONDENT (the person alleged to have caused harm).

Incident Date (approximate date okay) *

Incident Time (approximate time okay) *

:

Respondent's Name (If unknown, please write UNKNOWN in text box.) *

Respondent's Course ID, if known (e.g. DESMA X 479.6A - 372742)

Respondent’s Classification *

Please provide a brief description of the incident. *

Tips: To the best of your ability and memory, please provide objective and observable information (For example, do not report that Sue "looked drunk"; report that Sue "slurred her speech and her breath smelled of alcohol"). Do not censor explicit language. Do not diagnose the behavior. If it is easier to make a verbal Title IX report, please stop filling out this form and contact the UCLA Title IX Coordinator: https://equity.ucla.edu/about-us/our-teams/civil-rights-office/

Please Note: This is an official document that may be reviewed by the respondent and may become subject to a Public Records Request.

What outcome or remedy are you requesting for this incident? *

I attest that the information included in this form is factual and complete to the best of my knowledge. I understand that submission of this form does not require Extension to formally investigate my claim. I understand that providing false statements in bad faith is a violation of the Conduct Code subject to disciplinary action, and that incident reports may not be used to retaliate or otherwise block an open investigation. *

I agree

I do not agree