Climate Concern External Submission Form

First Name:

Last Name:

Role in Incident

Target Witness Informed by Target

Email:

Phone:

Preferred Contact Method:

Email Phone

Relation to Villanova:

Incident Details

Date of Incident:

or approximate time frame if the incident is ongoing

Time of Incident:

or enter approximate time of day

Role of Alleged Offender:

Student Staff Faculty Administrator Contract Employee Unknown Other

Explain Other Offender:

Location of Incident:

Classroom Campus Building At Campus Event Parking Lot Campus Office Residence Hall Walking On Campus Off-Campus Other

Explain Other Location:

Describe Incident:

Please note that the completion of this form does not replicate or replace existing processes to review and resolve complaints made on the basis of bias. A member of the Campus Climate Resource Network will make referrals to appropriate offices or person who will then investigate and respond to incident reports.

Confidentiality

To the extent possible, the university will maintain the confidentiality of all parties involved in a climate concern report. Confidentiality, however cannot be guaranteed.

CLIMATE CONCERN │EXTERNAL SUBMISSION FORM

Incident Details

Confidentiality