Bias Related Incident & Hate Crime Report Form

Reporting Form

The following form can be used to report a bias incident or hate crime to the Director of Human Resources. The report can be completed anonymously.
Name:
Email, if you wish to be contacted for further information:
example@example.com
Date of Incident:*

MonthDayYearHourMinutesAM/PM Option
Location(s) the incident occurred:*
Is the person completing this form a:*

Target / VictimWitnessOther
Please Specify:
How many people were involved in this incident:*
Do you know or believe you know the person(s) responsible for the incident?*

YesNo
Please Specify:
Please describe the perpetrator(s) in as much detail as possible. Include name, gender, phsyical characteristics etc.*
Please describe what happened in as much detail as possible. Include times, location, number of witnesses and why you believe this incident was motivated by bias:*
What protected group do you believe was targeted in this incident?*

RaceNationalityEthnicityGender/transgender identitySexual orientationReligionAbilityOther
Please Specify:
What form(s) did the incident take? Please check all that apply.
Written/Verbal

VerbalMailEmailTelephone CallSocial MediaGraffitiOther
Please Specify:
Vandalism

In or near residence hallVehicleWork spacePersonal propertyAdministrative or Academic buildingOther
Please Specify
Physical Assault

Without a weaponWith a weaponSexual AssaultOther
Please Specify Type of Weapon:
Please upload any digital evidence relevant to the report:

Browse Files
(i.e. screenshot, picture, email) Cancelof
Should be Empty: