Improper Conduct Report Form

Identity of person(s) who are believed to have engaged in improper conduct:*
Date (or approximate dates) when conduct occurred:*
Circumstances or events that are believed to constitute improper conduct (provide as much detail as possible):*
Identity of potential witnesses or other persons with knowledge of these circumstances or events (to the extent known, include names, addresses, telephone numbers and other pertinent contact information):*
I believe that the above circumstances or events constitute improper conduct because (check all applicable):*
- it is a violation of a federal or state law or regulation;
- it is a misuse or misappropriation of University property or willful omission to perform a duty or intentional violation of a University policy;
- it is economically wasteful or involves gross misconduct, incompetence or inefficiency or creates for the University potential exposure to liability and financial irregularities;
- it is an action or activity that is the result of a criminal act;
- it is a significant threat to the health or safety of members of the University community;
- it is scientific misconduct;
- it is an unauthorized invasion, alteration or manipulation of records and computer files;
- it is a pursuit of a benefit or advantage in violation of the University’s conflict of interest policy;
- it is an interference with a University investigation conducted in accordance with this policy, including the withholding, destruction or tampering with evidence or any effort to influence, coerce, intimidate or retaliate against an individual who has reported suspected improper conduct or witnesses.
Additional information you wish to provide the university:

Contact Information (Optional )
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Email
Best time or method for contacting you
I request and authorize each of the following checked items:
- I would like my identity to be kept confidential to the extent feasible. I understand that the University cannot guarantee against the disclosure of my identity.
- I authorize the University to disclose my identity.
- I am prepared to meet with a representative of the University to provide supplemental information relevant to any investigation conducted by the University.
- I request that I be informed of the disposition of my report.

Improper Conduct Report Form

Step 1 of 2

Contact Information (Optional )