The Office of Institutional Equity and Compliance

Discrimination and Harassment Reporting Form

Incident InformationDate of Incident (If applicable and known. Otherwise, leave blank and explain below.)

Incident Description

Location of Incident

Person ReportingName (leave blank if you wish to report anonymously)

Email

Daytime Phone

Status

Student

Employee

Other

Relationship of person reporting to the parties involved

Person HarmedName (if known)

Email

Daytime Phone

Status

Student

Employee

Other

Is person aware this report is being made?

Yes

No

Any other person harmed?

Yes

No

If yes, provide information

Person(s) AccusedName (if known)

Email

Daytime Phone

Status

Student

Employee

Other

Is person aware this report is being made?

Yes

No

Any other person accused?

Yes

No

If yes, provide information

Law Enforcement InvolvementHas law enforcement been notified?

Yes

No

Unknown

Office of Institutional Equity
and Compliance
1301 East Main Street
116 Cope Administration Building
Murfreesboro, TN 37132

615-898-2185 Phone
615-904-8041 Fax

Please send comments or complaints to iec@mtsu.edu

Middle Tennessee State University © Nondiscrimination Policy Terms

Last Updated: Aug 24, 2023