The Chemical and Biological Microsystems Society (CBMS)

Please answer all relevant questions and skip those that do not apply. Your information is confidential and will be handled according to CBMS ethical policies. You may report anonymously or allow follow-up contact. Details provided will help ensure a fair and complete review.

Complainant (This is the person who presents as the victim of the reported conduct.)
First/Given Name:
Last/Family Name:
Phone:
Email:
Country of residence:
* Are you the complainant?:
If you are not the complainant, please provide your name and contact information below to enable us to follow up with you, unless you wish to make an anonymous report:
Your First/Given Name:
Your Last/Family Name:
Your Phone:
Your Email:
Country of residence:
Basis of Complaint
	Sexual Misconduct This includes sexual harassment, assault, violence, stalking, exploitation, complicity in prohibited acts, and retaliation for reporting. A full description is provided in the CBMS Conduct Policy.
	Misconduct based upon protected characteristics including, but not limited to, actual or perceived gender, gender identity, race, ethnicity, sexual orientation, ability, socioeconomic status, age, or religion. This includes bullying, intimidating or demeaning speech, humiliation, physical assault, threats of harm, and other unprofessional or inappropriate behaviors. A full description is provided in the CBMS Conduct Policy.
Respondent(s) (This is the person that committed the reported conduct.) Please provide information on the respondent below to the extent known. If you would prefer not to identify the respondent, skip this section.
Respondent Name:
Some people share the same name. To avoid ambiguity, please share other info if you have it, such as institutional affiliation, position/title, email address.
Additional Info:
Name unknown, but I have other identifying information.
Identifying Info:
Nature of Complaint
Date(s) of the Incident/Conduct:
Location(s):
The Incident/What Happened: Please provide a description of the incident/conduct you are reporting using specific, concise, and descriptive language (i.e., who, what, where, when, and how). Please also indicate your desired outcome, if applicable. Use additional pages, if needed.
Incident:
Witness(es), if Any: Provide the name and contact information (e.g. email address) of any witnesses.
Witness(es):
Attachments: If you have any supporting documentation (e.g., copies or screenshots of documents, emails, photos, text messages, and/or other evidence related to your report), please attach such items with this report.
File:
Recipients of Report By default, the report will be received by the CBMS Executive Committee (President, Vice President, Treasurer) and the Executive Director of CBMS (Sara Stearns). If you would prefer to exclude one or more of these committee members, such as due to a potential conflict of interest, you may do so. The current executive committee is listed here (President, Vice President, Treasurer) Please list below if you would like anyone to be specifically excluded from receiving the report.
Exclude:
Thank you for sharing this report. You can expect to be contacted within 2 business days for initial follow-up, and an investigation to occur within 30 days.