Testing Counseling Health Center Disability Support Services Alcohol & Drug Prevention Violence Prevention Student Threat Assessment Team Reporting This service is not an emergency hotline or a substitute for using emergency services. In the event of a life-threatening emergency, contact Campus Police at (254) 295-5555 or 911. Do You Wish To Remain Anonymous?: * Yes No Name: * I am a: * - Select -StudentFacultyStaffParentVisitorOther Please select an option. Type of Activity Reporting: * - Select -Criminal ActivityMistreatmentRapeSafety ConcernSexual HarassmentSexual AbuseSubstance AbuseTheftThreatening BehaviorViolation of University PolicyOther Phone Number: * Email: Location of Incident: * Approximate Date: * MonthJanFebMarAprMayJunJulAugSepOctNovDec Day12345678910111213141516171819202122232425262728293031 Year201620172018201920202021 Approximate Time: * hour123456789101112 : minute000102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859 am pm Incident Description: * Please List Individuals You Think May be Involved: * Please list the first and last name of at lease one individual. If there is no specific person OR you don't know the first or last name of an individual, please enter "unknown" in the field. Please indicate if any of these are not affiliated with UMHB. Did the incident occur more than once?: * Yes No How many times did this occur?: Were you directly affected by this situation/behavior?: * Yes No How were you affected?: Was there anyone injured?: * Yes No Please describe the nature of the injuries.: Who else may have witnessed the incident or is aware of the situation?: * Please list anyone you know of who also witnessed the incident. Also, please list anyone who is aware of the incident from any other manner besides directly witnessing it. If you are not sure of who may have seen it or become aware of it, please enter "unknown" in the box. Please indicate if any of these are not affiliated with UMHB. Was the incident reported to campus authorities?: * Yes No Who was it reported to?: Please describe who it was reported to, who made the report, and how it was reported. Additionally, please list if it was reported to anyone else. Other information: Please use this place to provide any other information you find important.