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Bias Incident Reporting Form


Purpose: This form is for reporting incidents of bias, intolerance, or intimidation. A bias incident is any discriminatory or hurtful act that appears to be or is perceived by the impacted person to be motivated by race, color, creed, religion, national origin, sex, gender, age, marital status, disability, public assistance status, veteran status, sexual orientation, or familial status. To be considered an incident, the act is not required to be a crime under any federal, state, or local statutes, nor does it have to violate university policy.

Once submitted it goes directly to the Dean of Students Office and members of the University's Bias Incident Response Team. Information obtained through this report will assist in determining the response to and tracking of incidents of bias.

If you prefer to report an incident in-person or through a Zoom meeting, please visit the Dean of Students Office webpage or Human Resources webpage to schedule a meeting.

If this is a matter that needs immediate attention because of concerns of health and/or safety, please contact MSUM Public Safety at 218.477.2449 or dial 911.

Completing this Form: Please enter as much of the information below as you are able. All information provided is considered voluntary. You are not legally required to provide this information. It is expected that any information that you provide is truthful.

Confidentiality cannot be guaranteed. The university will strive to protect, to the greatest extent possible, the confidentiality of the persons reporting and of those involved in the reported incident. The university may have an obligation to address certain reported incidents, including conducting an investigation and, when warranted, taking corrective action.

This report may be used by university administrators responsible for reporting data and statistics to Minnesota State system administrators, State of Minnesota officials, and federal agencies. The reported information may also be released in accordance to local, state, or federal laws or with your consent.

Anonymous reporting happens when you do not disclose your name and/or the identities of the other parties involved. Depending on what information is shared, action by the University may be limited.

Information for person making report

Anonymity: You may wish to identify yourself in this section, or you may choose to remain anonymous. It is understandable that there may be reasons a person may want to withhold their identity or other information requested here--at this time or indefinitely. Only the fields with red asterisks are required for submission.

 
This field is required.
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Involved Parties

Please list the individuals involved (excluding yourself), including as much information as requested as you are able to provide.

Involved party 1

Questions

This field is required.
Was this incident reported to any other campus agency or department? If yes, please indicate where in the Incident Description section above.(Required)
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Do you know who did this? If yes, please indicate who as the accused/offender(s) in the Involved Parties section above.(Required)
This field is required.
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Do you wish to be contacted regarding this incident? (If you are submitting the report on behalf of another individual, do they wish to be contacted regarding this incident?)(Required)
This field is required.
This field is required.

Supporting Documentation

Photos, video, email, and other supporting documents may be attached below. Maximum 12 megabytes per file Attachments require time to upload, so please be patient after you click to submit this report. 5GB maximum total size. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

Submission