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:  MonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember Day12345678910111213141516171819202122232425262728293031 Year20122013201420152016      Time:123456789101112:000102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859 AMPM

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):