Information and privacy: questions regarding the collection of information on this form can be directed to the form administrator.

The service unit you had an issue with on campus? * (required)
Select all that apply
How would you describe the type of injustice/hate? * (required)
Select all that apply
(i.e. classroom, building, outside, inside, residence etc.)
Optional Self-Report
May we contact you?

Please Note: Please Note: By selecting "yes" to any of the following 2 questions, your contact information will be shared with the appropriate group.

Would you like the support of a Service Peer Supporter? * (required)
If yes, which Service would you like a Peer from?
(Select all that apply)
Would you like to be referred to an on-campus University run service? * (required)
(eg: Counselling Services)
If yes, which one?
(Select all that apply)

Would you like the Waterloo Undergrad Student Association to report the incident to the appropriate area(s) on your behalf?
Do you want your contact information shared with the appropriate service unit(s) you selected?
The information in this form will be sent to the WUSA Services Manager and distributed appropriately per the answers you provided. By submitting this form, you are allowing WUSA to use this information in its advocacy efforts and to record and track incidents happening on our campus in order to help improve the experience for marginalized folks on campus.
The information in this form will be sent to the appropriate persons of any selected services as well as the Vice President, Student Life. By submitting this form, you are allowing WUSA to use this information in its advocacy efforts and to record and track incidents happening on our campus in order to help improve the experience for marginalized folks on campus.