Incident Reporting Form

Incident Reporting Form

*Edit the fields below according to your needs.

Other Conduct of Concern Incident Report

The Other Conduct of Concern Incident Report is available for anyone in the CSUSB community—students, faculty, staff, campus visitors, or guests—who has experienced or witnessed an incident or behavior that needs to be reviewed or resolved.

Submitting this form alerts the Review Team to review the incident report and refer it to the appropriate office for next steps. Including contact information and thorough details about the incident allows us to reach out with resources and support in navigating options. Please visit the CSUSB Other Conduct of Concern site for more information.

The Other Conduct of Concern Incident Report Form is for non-emergency incidents. If you need to report an emergency, call University Police dial 9-1-1.

Concerns regarding allegations of Discrimination, Harassment, and Retaliation as it related to a protected status, as well as Sexual Misconduct, Sexual Harassment, Dating/Domestic Violence, and Stalking should be reported using the Institutional Equity & Compliance Incident Reporting Form

Concerns regarding workplace violence should be reported using the Workplace Violence Reporting Form

Concerns of behavior involving students should be reported using the Student Conduct Incident Reporting Form

Resources:

Employee Assistance Programs

Office of Institutional Equity and Compliance

Title IX Resources

Workplace Violence Prevention Program

Individual Reporting Other Conduct of Concern

Date*

Your Name*

Your Coyote ID*

Your Role at CSUSB*

Faculty, Staff, Student, MPP, Other.

Select or enter value

Your Division*

Select or enter value

Date of incident(s)*

Location of incident(s)*

Please tell us about the PEOPLE involved in the incident.

Complainant: The person who the was the target of the alleged conduct.

Respondent: The person who is alleged to have engaged in the conduct.

Witness: Anyone who saw some or all of the alleged conduct.

You MUST include yourself, including your Coyote ID number and your EMAIL.

Full Name

Select Role

Select

Coyote ID Number (if known)

Phone Number

Phone

Email Address

Add Another Party?

Yes

Full Name

Select Role

Select

Coyote ID Number (if known)

Phone Number

Phone

Email Address

Add Another Party?

Yes

Full Name

Select Role

Select

Coyote ID Number (if known)

Phone Number

Phone

Email Address

Add Another Party?

Yes

Full Name

Select Role

Select or enter value

Coyote ID Number (if known)

Phone Number

Phone

Email Address

Add Another Party?

Yes

Full Name

Select Role

Select

Coyote ID Number (if known)

Phone Number

Phone

Email Address

Questions

Summary of the incident - Please provide all known information regarding the incident as it occurred or was reported to you, including a detailed description of the incident/concern using specific concise, objective language (i.e., who, what, when, where, why, and how).

Detailed description of incident:*

Have any other departments been contacted regarding this incident?*

Yes

I do not know

Please select the department(s) you contacted regarding this incident*

CSUSB Counseling and Psychological Services

CSUSB Risk Management Office

CSUSB Faculty Affairs & Development

CSUSB Office of Institutional Equity and Compliance

CSUSB Office of Student Conduct and Ethical Development

CSUSB Human Resources

CSUSB University Police

Other

Supporting Documentation

Please attach any photos, video, email, or other supporting documents.

Attachments require time to upload, so please be patient after submitting this form.

Drag and drop files here or

Send me a copy of my responses

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