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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
Sexual Misconduct (Title IX)
IMPORTANT: Please note that this is not a confidential form. We are required to report any claim of sexual violence/harassment to the UCLA Title IX Coordinator, which may prompt an official investigation. If you wish to speak to a Title IX Investigator about receiving supportive measures, please email SRRC@unex.ucla.edu or call 310.825.0953 to discuss your options.

You may also report directly to the UCLA Title IX Coordinator, even anonymously:

Mohammed Cato
2255 Murphy Hall
Email: titleix@conet.ucla.edu
Phone: (310) 206-3417
I understand that submitting this report will result in a member of the SRRC team contacting me regarding my options. I also understand that submitting this report DOES NOT automatically initiate an investigation. *

You have indicated that you are not interested in completing this report. There is no statute of limitations to file a claim of sexual harassment. If you change your mind, we are here to help. Please exit the form now.

https://www.sexualharassment.ucla.edu
Staff/Instructor Conduct
Official student/instructor grievances will only be reviewed under three narrow circumstances. If you wish to make a general complaint that does not meet the grounds for this report, you may pursue resolution through the department. To locate the appropriate unit manager or Program Director, please visit the UCLA Extension "contact us" page on our website.
Grounds for complaint (Please choose the most applicable.) *
Explain *:
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 *
Student 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? *
Academic Integrity
This form is to be used by instructors to independently resolve alleged low-level academic integrity violations. If the incident includes other matters of conduct (harassment, fraud, etc.) or you wish for the SRRC to handle directly, please complete section 1 without attaching this form. If more than one student is suspected of a violation, please submit a separate form for each student.
Are you an instructor who is making a claim of academic dishonesty by a student in your course? *
Do you wish to resolve the matter independently with the student? *
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. *