SIUE Bias Incident Report Form

Background Information

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Your full name:

Your position/title:

Your phone number:

Your email address:

Date of incident(Required):

This field is required.

Time of incident:

Location of incident(Required):

This field is required.

Specific location:

Involved Parties

If you know the individuals/organizations involved in this incident please provide their names below. If you do not know who is involved, leave this section blank.

Name or Organization

Select Role

ID Number (if known)

Questions

Please provide a detailed description of the incident/concern using specific, concise, objective language. If you have listed an individual as an involved person, that person should appear at least once in the narrative. Please provide as much detail as possible in regards to the behavior(s) that prompted the report. Reports are reviewed by members of the Bias Incident Response Team. If you are concerned for the immediate health and safety of yourself or others, please call 911.(Required) This field is required.

Are you a victim or witness to the incident?(Required)

Victim Witness Other

This field is required.

Have the police responded to this incident?(Required)

Yes No Unknown

This field is required.

How would you prefer to receive follow-up?(Required)

Phone Email No follow-up

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

Questions

Supporting Documentation

Submission