ÃÛÌÒ´«Ã½ Suspected Child Abuse Report Form

If you believe you may have witnessed child abuse on the ÃÛÌÒ´«Ã½ campuses or in UB programs and activities, you may either complete this form, call us at (716) 645-2266 or dial campus police at (716) 645-2222.

 

Information About the Incident

 
mm/dd/yyyy
 
Include whether a.m. or p.m.
Type of Abuse
Type of Abuse
 
 
 
 
 
 

Check all that apply

 
Be as specific and detailed as possible to the best of your recollection.

Information About the Victim(s)

 
 
Approximate age if unknown

Information About the Abuser

 

Information About Additional Witnesses

Were there any witnesses to the situation or treatment you have described other than yourself?
Were there any witnesses to the situation or treatment you have described other than yourself?
 
 
 
 
 
 
 

Who Have You Shared This Experience With So Far?

Have you spoken to anyone about your concerns?
Have you spoken to anyone about your concerns?
 
 
 
 
 
 

CONFIDENTIALTY STATEMENT

The Office of Equity, Diversity & Inclusion (EDI) and ÃÛÌÒ´«Ã½ Police will make every effort to maintain confidentiality except in situations where law, ÃÛÌÒ´«Ã½ policy, or the investigatory process requires the release of information.

Providing your name and contact information is optional. If you choose to provide this information, it will assist with an investigation and follow-through. Each complaint will be investigated to the best of the ÃÛÌÒ´«Ã½’s ability, based upon the information provided.

Retaliation against an individual who reports suspected child abuse/inappropriate conduct is strictly prohibited.

Information About You (the person filing this report)--optional

 
 
 
Preferred Method of Contact:
Preferred Method of Contact:
 
 
 
 
 
 
ÃÛÌÒ´«Ã½ Affiliation:
ÃÛÌÒ´«Ã½ Affiliation:
 
 
 
 
 
 
 
 
 
(Required)