Office of Student Conduct Hazing Report Form

Individual Reporting the Incident: (Can report anonymously but it makes it much more difficult for us to follow up and address the behavior)

First Name:      Last Name:

FAU Z Number (if student/faculty):

E-mail:   Phone Number (10 digits):

Date of Incident:   Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 2012 2013 2014 2015 2016       Time: 1 2 3 4 5 6 7 8 9 10 11 12 : 00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 AM PM

What organization was involved in the hazing?

Location of Incident: 

Witnesses to the Incident (please list all witnesses):

Was anyone injured?  Yes   No

Was alcohol involved?  Yes  No

Were any organization advisors present? If so, who:  

Were any organization officers/leaders present? If so, who:

Were any team coaches present? If so, who:

Please describe in as much detail as possible what happened:

I agree that the above statement is true and accurate to the best of my knowledge. I understand that I may be contacted by the Office of Student Conduct to provide further information or serve as a witness for a student conduct hearing.

Electronic Signature (type your name):