Bias Incident Report Form

Background Information

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Your full name:

Your position/title:

Your phone number:

Your email address:

Email address must be of a valid format.

Your physical address:

Date Observed(Required):

This field is required.

Time Observed:

Location of incident(Required):

This field is required.

Specific location:

Involved Parties

Name or Organization

Select Role

ID Number

DOB (YYYY-MM-DD)

Phone number

Email address

Hall/Address

Questions

Please provide a detailed description of the incident/concern using specific concise, objective language (who, what, where, when, why, and how). The use of direct quotes is encouraged. Avoid using pronouns when multiple individuals are involved. These reports are submitted to the Bias Incident Response Team.

Tell us about your complaint and why you feel it is bias related.(Required) This field is required.

Other than reporting this to the Bias Incident Response Team, have you taken any other steps to address this incident/concern?(Required) This field is required.

What are you hoping for as an outcome?(Required) This field is required.

Are there witnesses and/or other information we need to know?(Required) This field is required.

How have you been impacted by what you are reporting?(Required) This field is required.

Do you feel you need resources or support?(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.

Email me a copy of this report

Background Information

Involved Parties

Questions

Supporting Documentation

Submission