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OIED Impact Report Form


Please use this form to document OIED related behavior/action to NC State’s OIED Impact Response Team (IRT). This report can be submitted by individuals directly affected by behaviors/actions, observers, or those indirectly impacted (advisor, family, friends etc.)

You may submit an impact report anonymously. However, in order for us to follow up and provide the necessary support to impacted persons/groups, we encourage you to include our contact information. All reports are held confidentially to the fullest extent possible by federal and state law. NC State strives to honor the wishes of Reporters and/or Involved persons/groups but may need to pursue additional actions to protect the health and welfare of impacted persons and the broader University community.

Do not use this form to report an emergency. If this incident requires police, fire or medical attention, please dial 911 or NC State Campus Police at (919) 515-3000 immediately. Impact Reports are reviewed during normal business hours and are not monitored after hours, on weekends, or during official University holidays. While reports are reviewed by a variety of campus partners working to assist students and employees, it is NOT designed for emergency response.

Reporter Information

 
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Name of person completing this report
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Student, Faculty, Staff, Alumni, Parent, Visitor, etc
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(if applicable)
Email address must be of a valid format.
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Involved Persons

Please provide as much information as you can about the individuals/groups involved, including the name(s) and contact information (if available) of observers. If you are the reporter AND an involved person, please include your information as well. If an individual's identity is unknown, please include descriptive information about that individual in your report narrative.

Please consider the following when identifying the role of each involved person/group: 

  • Observer/Affected Person/Group - Those indirectly impacted by the behaviors/actions of a Responsible Person(s) or that observed the behavior/action but are not impacted.
  • Impacted Person/Group - Those who are directly impacted by the behaviors/actions of a Responsible Person(s).
  • Responsible Person(s) - Those whose behaviors/actions have impacted others and/or the community.
  • Supporter(s) - Advisors, friends, family, etc. of either Impacted, Affected or Responsible Person(s) that offer assistance, encouragement, or other supports.
Involved party 1

Impact Details

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The behaviors/actions experienced, witnessed, or reported to me include: (please select all that apply)(Required)
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The OIED Impact related behavior/actions focused on the following actual or perceived identity(-ies): (please select all that apply)(Required)
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IRT strives to uphold the privacy wishes of those who submit OIED impact response reports. It is important to note that, in order to comply with federal, state and local laws, as well as NC State policies, some information within this report may be required to be shared.(Required)
You must make at least one selection.

Supporting Documentation

Please upload any photos, video, email, and other supporting documents to be attached to this report.

5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

Submission