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Please summarize your report in a few words.

Describe your report in detail.

Where did the incident or incidents occur?

When did the incident or incidents occur?

How were you involved in the incident or incidents?

Can you substantiate your report?

Yes

No

Have you already reported the incident(s) to another institution/person?

Yes

No

Where have you already reported the incident(s)?

Do you have any other comments?

Do you want to make this report anonymously?

Yes

No

I take note of the privacy policy.

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