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Would you like to be anonymous in reporting this incident?

Would you like this incident to remain confidential to the CHM Student Ombudsperson?

Do you want this incident investigated or do you just want us to be aware of the incident?

Do you hope for a particular outcome given this report and/or interaction with the Student Ombudsperson? 

Which campus or community are you in?

What academic year or program are you in?

May the Student Ombudsperson contact you?