USM Bias Incident Report Form

Background Information

Your full name:

Faculty, staff or student?:

Your phone number:

Your email address:

Your physical address:

Type of incident(Required):

This field is required.

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Possible Motivation(Required):

This field is required.

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Date of incident(Required):

This field is required.

Approximate time of incident:

Location of incident(Required):

This field is required.

Specific location:

Involved Parties

Name or Organization

Select Gender

Select Role

ID Number

DOB (YYYY-MM-DD)

Phone number

Email address

Hall/Address

Incident Narrative

Please provide all details to the best of your recollection.

Please describe what you know about this incident and how this occurred.(Required) This field is required.

Please describe the offender(s)'s appearance, including but not limited to: name, gender, approximate height and weight, skin color, hair and eye color, facial hair descriptions, what they were wearing as far as clothing, glasses or no glasses, and other distinguishing characteristics.(Required) This field is required.

Please list any additional witnesses or impacted community members (and how we might contact them).(Required) 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.

Background Information

Involved Parties

Incident Narrative

Supporting Documentation

Submission