University at Buffalo - The State University of New York
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Information Intake Form

If you are considering a report of discrimination or harassment and would like to be contacted, please fill out this form.

After receiving your information, a representative of Equity, Diversity and Inclusion (EDI) will contact you within one business day.

  • You should report any crime in progress or other emergency to University Police at (716) 645-2222. 
  • You may contact EDI anonymously, either for consultation or to file a complaint.  Please understand that due process considerations may limit our ability to investigate or resolve anonymous complaints.

If you do not wish to provide the information to a particular question, please leave that field blank.

 
 
 
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Gender - Check as many as apply
Gender - Check as many as apply
 
 
 
 
Race/Ethnicity - Check as many as apply
Race/Ethnicity - Check as many as apply
 
 
 
 
 
 
 
 
Are you concerned that this situation or treatment was the result of one or more of the following?
Are you concerned that this situation or treatment was the result of one or more of the following?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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UB offers a Conflict Resolution Program as an alternative to filing a complaint. Are you interested in receiving information about the program?
UB offers a Conflict Resolution Program as an alternative to filing a complaint. Are you interested in receiving information about the program?
 
 
 
(Required)

Confidentiality Statement

Equity, Diversity and Inclusion will make every effort to maintain confidentiality except in situations where law, University policy or the investigatory process requires the release of information.  EDI will not release information without informing you.

Prohibition against Retaliation

Retaliation against an individual who files a complaint and/or participates in an investigation is strictly prohibited, and may result in disciplinary action.