Qualtrics Survey | Qualtrics Experience Management

Name: Last, First, Middle Initial

Address: Street, City, State, Zip Code

Phone Number: Format 123-456-7890

Secondary Phone Number: Format 123-456-7890

Email Address

Incident Date & Time (approximate)

Incident Location (Address, Building, Street, etc.)

Witnesses to the Incident (If Known)

KU Officer Involved or other KU Police Department Employee Involved (if known)

Description of the Incident (be as specific as possible)

What is your desired outcome for this incident?

By typing "I ACCEPT" you verify that under the penalty of perjury that the information filled out above is true and correct to the best of your knowledge.

Today's Date & Time