Code of Conduct Reporting

First Name:

Last Name:

I am:
(check all that apply)

Your Email:

Your Phone:

If phone, may a message be left?
Yes No

Is the Respondent a student at Western University? (Please choose one): Yes No I don't know

Student's First Name:

Student's Last Name:

Student's Western Email:

Student's Phone Number:

Witness Name(s):

Contact information for possible witness(es):

Location of Incident:

Incident Date:

(Approximate)Time of Incident:

Type of Incident:

Please briefly describe the incident of concern:

Has this incident been reported elsewhere on campus? (please check all that apply)

CCPS

Housing

Equity

Please note: While anonymous complaints may be received, Western will have limited ability to respond to such complaints.

You will be contacted within 72 hours by a member of the Conduct Office to confirm the formï¿½s information and to review the next steps.

Code Complaint Form