Bias Report Form

Background Information

Your report will be completely anonymous unless you enter your name and contact information, which are optional.

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Your full name:

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You can type ANONYMOUS

Your position/title:

Your phone number:

Your email address:

Email address must be of a valid format.

Your physical address:

Date of incident(Required):

This field is required.

Time of incident:

Location of incident(Required):

This field is required.

Specific location:

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(example: Room 331)

Involved Parties

Please list the names of ALL individuals (or organizations/groups) involved and impacted, including yourself. If you do not know all information for an individual, complete as much as you can.

Name or Organization

Select Gender

Select Role

ID Number

DOB (YYYY-MM-DD)

Phone number

Email address

Hall/Address

Questions

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