Protected Identity Harm Reporting Form

Incident Details

To Everyone:

This form is defaulted to be anonymous. You are not required to add your name here, especially if you want to remain so. However, if youwant to be contacted see notes below. ALSO, indicate in the last question that you want to be contacted.

Note for Students: This process was set-up to collect data and if you so chose, connect you to resources and potential resolutions.

Note for Faculty/Staff/Postdoctoral Appointee: If you choose to be contacted, there is a limited capacity on our resolution processes for faculty, staff, and postdoctoral appointees.

Note for All Others: At this time if you chose to be contacted there is very limited capacity in our abiilty to respond to anyone who is not a student, faculty member, staff, or post-doctoral appointee.

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Name:

Your email address:

Date of incident(Required):

This field is required.

Time of incident:

Where did this incident occur?(Required):

This field is required.

Please specify the location:

Involved Parties

Name of Person or Organization

Questions

If there is a social media or online component of this report, where were you when you received or viewed the material you are reporting? Type N/A if this does not pertain.(Required) This field is required.

Are you reporting this on behalf of someone (e.g. someone shared information with you to share here OR you are mandated to report information via this form)?(Required)

No Yes

This field is required.

Please indicate your classification

Stanford undergraduate student Stanford graduate or co-term student Stanford postdoctoral appointee Stanford faculty Stanford staff Non-affiliate

This field is required.

What happened? Please give as many details as possible, including place, person(s) involved, and pertinent circumstances of how the bias was demonstrated. Describe the incident, being as specific and including as many factual details as possible or any known affiliations of people who are involved. Give as many of the facts supporting the report (comments, markings, gestures, property damage, physical injures and other conduct) as you can. Share if helpful, how it impacted you. If this occurred during a class, please indicate the course number.(Required) This field is required.

Who is/are the targeted party/parties? (Check all that apply.)

Stanford undergraduate student Stanford graduate or co-term student Stanford postdoctoral appointee Stanford staff member Stanford faculty or lecturer Non-affiliate Unsure

You must make at least one selection.

Within that protected identity, what specific identity was targeted? (For example, the specific religion, the specific gender identity; the specific country of origin, etc.) Or if you indicated "other" please describe below(Required) This field is required.

If the targeted party is a student (either graduate or undergraduate) or a post-doctoral appointee, please indicate their affiliation, if known.

Graduate School of Business

Graduate School of Education

Law School

School of Earth, Energy & Environmental Sciences

School of Engineering

School of Humanities and Sciences

School of Medicine

Undeclared undergraduate

Unknown

You must make at least one selection.

Can you categorize the alleged offending party's relationship to Stanford (choose all that apply)?(Required)

Stanford undergraduate student

Stanford graduate or co-term student

Stanford postdoctoral appointee

Stanford staff member

Stanford faculty or lecturer

Stanford Teaching Assistant

Stanford Student Organization

Other Non-affiliate

You must make at least one selection.

Describe the alleged offending party as best as you can This field is required.

Does the offending party know the targeted party/parties?

Yes No Unsure

This field is required.

Was a police report filed?(Required)

Yes No

This field is required.

Were you or anyone else impacted by these events feeling fearful or intimidated? Please include any additional information. Type "N/A" if this does not pertain.(Required) This field is required.

Please use this box to share anything else that concerns this report. This field is required.

One of the primary goals of the Protected Identity Harm Reporting process for students is to better understand the reason for reporting. Why did you choose to report this?(Required)

As an FYI: I do not want to be contacted As an FYI: I can be contacted if needed Because it impacted me and/or a community: I do not wish to be contacted Because it impacted me and/or a community: I wish to be contacted It impacted someone else but they do not wish to be contacted It impacted someone else who wishes to be contacted (you will serve as the intermediary)

This field is required.

Remember that if you filled out that you want to be contacted, be sure to include your name and email at the top of the form 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.

Incident Details

Involved Parties

Questions

Supporting Documentation

Submission