Bias Incident Reporting Form

Background Information

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Your full name or (Anonymous):

Your position/title:

Your phone number:

Your email address:

Your physical address:

Nature of report(Required):

This field is required.

Urgency of this report(Required):

This field is required.

Date of incident(Required):

This field is required.

Time of incident:

Location of incident(Required):

This field is required.

Specific location:

Involved Parties

Please list the names of ALL individuals (or organizations) involved and impacted, including yourself. If you do not know all of the information for an individual, complete as much information as you can.

Name or Organization

Select Gender

Select Role

Student L#

DOB (YYYY-MM-DD)

Phone number

Email address

Hall/Address

Reason(s) for Bias Report

Please provide as much detailed information as possible to better assist us in our investigation and possible corrective action(s).

Localized Bias Occurrence (Check all that apply)

Occurred within a limited area of campus (e.g., classroom, small group setting, resident’s room) Heard or witnessed by a small number of people

You must make at least one selection.

Community Bias Occurrence (Check all that apply)

Experienced, heard, or witnessed by a large number of people Widely known by a large number of people Repeated, patterned, or systemic occurrences

You must make at least one selection.

Description/Narrative - Please describe what happened in as much detail as possible. This field is required.

In your opinion, how could this be resolved? This field is required.

Supporting Documentation

Photos, video, email, and other supporting documents may be attached below. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

Email me a copy of this report

Background Information

Involved Parties

Reason(s) for Bias Report

Supporting Documentation

Submission