Achieving Community Together Reporting Form

Your Information

Your full name:

Are you faculty/staff/student:

Your phone number:

Your email address:

Email address must be of a valid format.

Type of Incident(Required):

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Please choose a general area of behavior

Possible Motivation(Required):

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What do you think motivated the incident? For example: race, sexual orientation, disability, etc...

What was the date?(Required):

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What was the approximate time?:

Location of incident(Required):

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School Affiliation:

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(Thayer, Geisel, Undergraduate, etc)

Involved Persons

Please enter in all of the information you know about any people (NOT including yourself) involved in the bias incident.

Name or Organization

Select Role

Email address

Incident Narrative

Please provide all details that you have to the best of your recollection.

Please describe the offender(s)'s appearance, including but not limited to: name, sex, 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 describe what you know about this incident and how this occurred.(Required) This field is required.

Please list any additional witnesses or impacted community members (and how we might contact them). This field is required.

Would you like a member of ACT to contact you within the next 48 hours to discuss next steps? If so, please provide your contact information below.(Required) This field is required.

Supporting Documentation

If you have received concerning communications such as emails, texts, notes, etc, and would like to share them now, please upload those along with your report. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

Email me a copy of this report

Your Information

Involved Persons

Incident Narrative

Supporting Documentation

Submission