Report a Concern Form | Central Washington University

HSRC Report a Concern Form

Please provide the following information about the incident of concern:

Date of Incident:

Field is required

mm/dd/yyyy

Time of Incident

Field is required

hour:minute

Time of Incident:

Incident Location:

Field is required

(on-campus, residence hall, academic building, off-campus, retail or grocery etc

Enter details of concern.

Field is required

Be specific about what you observed or experienced:

Do you want to remain anonymous? *

Yes

Field is required

Do you want to be contacted?

yes

Field is required

Full Name:

Phone:

(509) xxx-xxxx

Email:

Field needs to be a valid email address.