Incident Report Form

IF THIS IS AN EMERGENCY, please call security (Ext. 5555) or 911.

Please complete as much information as possible. The timing and manner in which the Lab responds to this report will vary depending on the information provided and whether you wish to remain anonymous.

This form can be used to report an incident involving an alleged violation of:

EEO Policy - Policy prohibiting discrimination, harassment, and retaliation in the workplace, and setting forth the Laboratory's procedures for handling complaints relating to alleged discrimination, harassment, and retaliation.
Interim Title IX - Title IX of the federal Higher Education law prohibits discrimination on the basis of sex in any education program or activity receiving federal assistance.
Whistleblower Policy - Policy outlining reporting procedures and protections available to CSHL employees (current or former), independent contractors, volunteers and students who seek to report workplace activities reasonably considered to be illegal or dishonest.

Your Information

Your Full Name:

Your Email Address:

Your Phone Number:

Your Current Address:

What type of report is this?: *

Date and Approximate Time of Incident: *

Location of Incident: *

Specific Location:

Please type a specific location

Involved Parties

Incident Information

*Please type a description of the incident, being as thorough as possible.

* Depending on the nature of an alleged incident, CSHL may be required to take action based on information contained in a report. In the course of an investigation, information will be shared as necessary with people who need to know, such as investigators, witnesses, and the respondent. Any response by CSHL may be hindered by the complainant's request for anonymity and/or inaction.

What type of resolution/next steps are you seeking by submitting this report?

I just want CSHL to be aware of this. I do not want this matter to be investigated.

I want CSHL to consider investigating this incident.

I'm not sure. I just wanted to file a report at this time.

* Please know that, depending on the nature of an alleged incident, a student who files a report may or may not be able to fully participate in a process or become aware of a resolution. With this in mind, to what level of involvement are you seeking in an investigation or resolution?

I will participate to whatever extent is necessary to address this matter.

I wish to be included as much as possible in the investigation and/or resolution.

I do not wish to be involved. I just wanted to submit a report to make CSHL aware.

I'm not sure at this time if I want to participate in any process.

Supporting Documentation (optional)

Photos, video, email, and other supporting documents may be attached below. Maximum 12 megabytes per file.
Attachments require time to upload, so please be patient after you click to submit this report.
If you wish to submit additional documentation, please do so here.

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Incident Report Form

IF THIS IS AN EMERGENCY, please call security (Ext. 5555) or 911.

Please complete as much information as possible. The timing and manner in which the Lab responds to this report will vary depending on the information provided and whether you wish to remain anonymous.

This form can be used to report an incident involving an alleged violation of:

EEO Policy - Policy prohibiting discrimination, harassment, and retaliation in the workplace, and setting forth the Laboratory's procedures for handling complaints relating to alleged discrimination, harassment, and retaliation.

Interim Title IX - Title IX of the federal Higher Education law prohibits discrimination on the basis of sex in any education program or activity receiving federal assistance.

Whistleblower Policy - Policy outlining reporting procedures and protections available to CSHL employees (current or former), independent contractors, volunteers and students who seek to report workplace activities reasonably considered to be illegal or dishonest.

Your Information

Involved Parties

Incident Information

Supporting Documentation (optional)