Dean of Students Office

Individual Reporting the Incident: (Can report anonymously but it makes it much more difficult for us to follow up and address the behavior)
First Name: Last Name:

UFID (if student/faculty):

E-mail: Phone Number (10 digits):

Date of Incident: JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember 12345678910111213141516171819202122232425262728293031 20082009 Time: 123456789101112: 000102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859 AM PM

What organization was involved in the hazing?

Location of Incident:

Witnesses to the Incident (please list all witnesses):

Was anyone injured? Yes No

Was alcohol involved? Yes No

Were any organization advisors present? If so, who:

Were any organization/team leaders present? If so, who:

Were any team coaches present? If so, who:

Please describe in as much detail as possible what happened:

I agree that the above statement is true and accurate to the best of my knowledge. I understand that I may be contacted by Student Conduct and Conflict Resolution to provide further information or serve as a witness for a student conduct hearing.

Electronic Signature (type your name):