Use this form to ask a question or report an incident. * Required Information Information entered on this form is secure and is only available to authorized employees. * Your First Name: * Your Last Name: Your Email Address or Your Phone Number is Required * Your E-Mail Address: * Your Phone Number: Hour 0 1 2 3 4 5 6 7 8 9 10 11 12 Minute 00 10 20 30 40 50 AM / PM AM PM Do you want your name kept confidential: Yes No Incident Date: Location of Incident: * Details of Concern or Question: If you are University of Utah Staff, Faculty, or Student: Employee / Student ID: Your Department: Submit
