Samford University






Person(s) Involved (include name and SID#)

List of Witnesses (include name and SID#)

University Staff Involved (include name and SU position)


Describe the incident in as much detail as possible


I attest that the account of this incident is given truthfully and without malice or bias. I understand that a copy of this report will be shown to the student(s) involved if there is sufficient evidence of a Values Violation. 


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