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Incident Information

Use this report for:

For Information Only
For Action

Date of Incident: (mm/dd/yyyy)

Time of Incident: (specify am/pm)

:

Location of Incident:

On Campus
Off Campus
Other

Other location Options:

Specific Location: (Dorm, Restaurant, etc.)

The Incident Was:

Description:

What is the perceived bias for this incident(?) (Check all that apply)

Other Percieved bias:

Person Harassing

Gender Identity:

Status:

Race / Ethnicity

African American / Black
American Indian / Indigenous / Native American / Alaskan Native / First Nation
Asian / Asian American
Latinx / Hispanic
Native Hawaiian, Pacific Islander
White
Another race or ethnicity that is not listed

Sexual Orientation:

Person Being Harassed

Gender Identity:

Status:

Race / Ethnicity

African American / Black
American Indian / Indigenous / Native American / Alaskan Native / First Nation
Asian / Asian American
Latinx / Hispanic
Native Hawaiian, Pacific Islander
White
Another race or ethnicity that is not listed

Sexual Orientation:

Person Completing Form

How I was involved:

Target of behavior
Witness to the incident
Friend of the target
Family member
Partner
Agency or staff person

Incident Status

Was the incident reported to a police agency?

Yes
No

If yes, what was the response/action and were you satisfied with their actions?

If no, what were the reasons for not reporting?

Was the incident reported to any campus agency or department?

Yes
No

If yes, what was the response/action and were you satisfied with their actions?

If no, what were the reasons for not reporting?

Contact Information (Optional)

You may choose to state your name or be anonymous. If you would like the Bias Response Team to help you explore options, look at alternative ways to deal with and resolve the situation, or advocate on your behalf, please leave your information so we may contact you. The report will be reviewed and followed-up with even if the reporter remains anonymous.

Name

Email

Phone