What University Department(s) is/are involved:_________________________________
What University employees, students, or others are involved:
Employee(s)_____________________________________________________________
Student(s)_______________________________________________________________
Other(s) ________________________________________________________________
Relationship(s) ___________________________________________________________
When did this occur – date or time period? ________________________________
How did you become aware of this problem?
Have you reported this to anyone else? Yes No
If yes, who ________________________________ and when ________________
Who else should we contact that would have relevant information?
Name _________________________________________________
Contact Information ______________________________________
Name _________________________________________________
Contact Information ______________________________________
Name _________________________________________________
Contact Information ______________________________________
Your Information
If you wish to remain anonymous, you do not have to provide contact information. However, we
encourage you to provide your contact information for any follow-up questions that may arise during
our review. However, if you provide contact information, and TTU has a separate legal obligation to
investigate the complaint (e.g., complaints of illegal harassment or discrimination), TTU cannot
guarantee anonymity or complete confidentiality.
Name _____________________________________________________
Address ___________________________________________________
Phone _____________________________________________________
Email _____________________________________________________
Please complete, print, and mail to Internal Audit, Campus Box 5154, Cookeville, TN
38505.