DIA Intake Form

DIA Intake Form

Report Anonymously

Requesting anonymity is your right to maintain; however, please understand that by checking this box, our inquiry into your concerns will be limited.

University Affiliation?

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Your Name

Your EID

Your Title

Your Phone Number

Your Email Address

Nature of Report

You may select all that apply

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Basis of Report

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Alleged Harm

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Please elaborate on the alleged academic harm:

Please elaborate on the alleged other harm:

Date of Incident

Multiple Dates?

Incident Date Range

Example (1/1/2019 to 3/1/2020)

Location of Incident

Complainant Name

Person who experienced misconduct

Complainant Gender

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Complainant EID

Complainant Title

Complainant Designation

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Respondent Name

Person who allegedly engaged in misconduct

Respondent Gender

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Respondent EID

Respondent Title

Respondent Designation

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Detailed Description of the Incident

Desired Outcome

Witness Name

Witness Gender

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Witness EID

Witness Title

Witness Designation

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File Upload

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