Confidential Suspected or Known Wrongful Conduct Report Form
* Items with an asterisk are required.
After submitting this form, do you want someone from the Office of Compliance, Ethics, and Integrity Services (CEIS) to follow up with you? (if yes, you must provide an email and/or phone number below)
*
Yes
No
Name:
First Name
Middle Name
Last Name
Association with PNWU:
*
Please Select
Student
Alumni
Employee
Trustee
Volunteer
Vendor
Community Member
Other
If other, please describe:
*
Email:
example@example.com
Phone Number:
Please enter a valid phone number.
Your role in the incident:
*
Please Select
Witness
Harmed party
Incident was reported to me
Other
If other, please describe:
Date of incident:
*
.
Month
.
Day
Year
if unknown, use an approximate start date; if ongoing, use a start/approx. start date
Describe the violation, concern, or misconduct including date, time, place, person(s) involved and any pertinent facts, details, and circumstances. If known and applicable, provide the name of the
associated policy
and/or procedure.
*
Explain prior attempts to resolve the issue informally (e.g., discussed/shared with the individual/group in question) OR the reason(s) why such attempts are not appropriate.
Other than informal attempts to resolve, has this been reported to any other unit (office/department/committee/program)? If yes, when and to whom?
What outcome or resolution are you seeking in regard to this report? The Office of CEIS will be prudent and fair in considering your suggestion(s).
Please upload any supporting documents
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