Discrimination Incident Reporting Form

Background Information

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Your full name:

Your affiliation:

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Student, Employee, Alumnus, Not Affiliated

Your phone number:

Your email address:

Email address must be of a valid format.

Primary Concern(Required):

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If more than one, select one and note additional in your description below.

Date of incident(Required):

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Please use 0000-00-00 if date of incident is unknown

Location of incident(Required):

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Specific location:

Involved Parties

Please list the individuals involved, including as much information as you can provide.

Name or Organization

VCU Affiliation

ID Number

Phone number

Email address

Address

Questions

Please provide a detailed description of the primary concern indicated above. If you have more than one concern, please also describe it here.(Required) This field is required.

Supporting Documentation

Please attach additional documentation if needed. Photos, video, email, and other supporting documents may be attached. Maximum 12 megabytes per file. Attachments require time to upload, so please be patient after you click to submit this 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

Background Information

Involved Parties

Questions

Supporting Documentation

Submission