Incident Details

	♦ What is the primary issue involved?
What	(Select One) If you feel the incident involves more than one of these issues, please choose the one most significant in your eyes and list the other issue(s) in your detailed description of the incident, below.
	Description: (No Issue Selected)

	♦ What specific behavior occurred?
	(Select One) If you feel that multiple behaviors were involved, please select the one most significant in your eyes and list the other behavior(s) in your detailed description of the incident, below.

♦ What is the primary type of bias involved?

Race Ethnicity, Ancestry or National Origin Religion or Creed Gender Identity or Expression Sexual Orientation Color Socioeconomic or Class Status Disability or Medical Condition Age Anti-Black Anti-Semitic Anti-Asian Islamaphobic Homophobic Transphobic Anti-immigrant Unknown (Select One) If you feel that multiple types of bias were involved, please select the one most significant in your eyes and list the other type(s) of bias in your detailed description of the incident, below

	♦ Please provide a detailed description of the incident.

	Where did the incident take place; Campus, Area, Location.

Where	♦ Campus Agriculture & Natural Resources Berkeley Davis Irvine Los Angeles Merced Riverside San Diego San Francisco Santa Barbara Santa Cruz Office of the President Lawrence Berkeley Lab (Select One)

	♦ Area Classroom Laboratory Library Office Campus Housing Campus Dining Campus Health Center Student Center/Bookstore Medical Center Main Campus Indoor Area Main Campus Outdoor Area Off-Campus Site Other (Select One)	♦ Other (Please Specify)

	♦ Location
	(Specific location, such as building name, address or cross-street.) Examples: Next to the dumpster, next to the field house. In the lab, storage room. Main Campus library third floor woman's restroom.

	♦ Date and time of the alleged incident:
When	(Ex: Monday, May 24th in the evening; the week of May 23rd; sometime in April 2010.) If you don't know the exact date & time, please provide an approximate timeframe or specify 'not sure'.

	♦ How long do you think this has been going on?
	Once One week One to 3 months 3 months to a year More than a year Don't know (Select One)

	♦ How did you become aware of the problem? It happened to me I observed it I was responsible I was a participant I heard about it from the victim I heard about it from a witness I heard about it from the presumed responsible party I heard about it from a participant I got a phone call or text message I found a photo, document or recording I saw it on the Internet: FaceBook, MySpace, etc. Other (Select One)	♦ Other (Please Specify)

	Have you previously reported this incident to the campus police or another University official?
Previously Reported	Yes No (Select One)

	Please indicate the office & individual you communicated with

Your Information

	Although you can choose to report anonymously, more information may be needed in order to respond appropriately to this incident. If you provide your contact information, your identity will be kept confidential to the extent possible under law. If you remain anonymous, please check back on your report periodically to see if the University has any follow-up questions for you.
	♦ Do you wish to remain anonymous?
Anonymity	Yes No (Select One)

Relationship	♦ Relationship to the University? Alumni Contractor Faculty Family Member Friend Graduate Student Intern Member of the Public Parent Patient Post-Doc Resident Staff Supervisor Undergraduate Student Vendor Visitor None Other (Select One)	♦ Other (Please Specify)

	We collect the following information so that we can identify populations that are/are not likely to report incidents. We want to improve the reporting process to be inclusive for all. This information is optional, and has no bearing on whether or not we address the issue you're reporting.

Demographics	Age Under 18 18 - 20 21 - 25 26 - 30 31 - 39 40 - 49 50 - 59 60 or Older (Select One)

	Race/Ethnicity African American American Indian Chicano/Chicana Chinese Filipino/Pilipino Japanese Korean Latino/Latina Middle Eastern Other Asian Pacific Islander/Native Hawaiian Pakistani/East Indian Vietnamese White Multiple Other (Select One)	Other (Please Specify)

	National Origin United States Korea (Republic of Korea) Japan China Taiwan India Mexico Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia & Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Congo (DRC) Cook Islands Costa Rica Cote d'Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island & McDonald Islands Holy See (Vatican City State) Honduras Hong Kong Hungary Iceland Indonesia Iran (Islamic Republic of Iran) Iraq Ireland Isle of Man Israel Italy Jamaica Jersey Jordan Kazakhstan Kenya Kiribati Korea (Democratic People's Republic) Kuwait Kyrgyzstan Lao People's Democratic Republic Latvia Lebanon Lesotho Liberia Libyan Arab Jamahiriya Liechtenstein Lithuania Luxembourg Macao Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russian Federation Rwanda Saint Barthélemy St Helena, Ascension & T da C Saint Kitts & Nevis Saint Lucia Saint Martin (French part) Saint Pierre & Miquelon Saint Vincent & the Grenadines Samoa San Marino Sao Tome & Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa S Georgia & S Sandwich Islands Spain Sri Lanka Sudan Suriname Svalbard & Jan Mayen Swaziland Sweden Switzerland Syrian Arab Republic Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad & Tobago Tunisia Turkey Turkmenistan Turks & Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Venezuela Viet Nam Virgin Islands, British Virgin Islands, U.S. Wallis & Futuna Western Sahara Yemen Zambia Zimbabwe Other (Select One)	Other (Please Specify)

	Gender Female Male Transgender FTM Transgender MTF Two-Spirit Genderqueer Other (Select One)	Other (Please Specify)

	Sexual Orientation Asexual Bisexual Gay Heterosexual Intersex Lesbian Queer Other (Select One)	Other (Please Specify)

	Religion or Creed Adventist Agnostic Atheist Baha'i Buddhist Catholic Gnostic Hindu Jain Jehovah's Witness Jewish Mormon Muslim Orthodox Christian Protestant Sikh None Other (Select One)	Other (Please Specify)

Participants

	How would you describe your relationship to the person you presume is primarily responsible? This person is my ____________(so that we may understand the relationship between the reporter and the alleged person responsible).

Relationship to Participant	Relationship Acquaintance Advisee Advisor Classmate Colleague Friend Instructor Intern Self Resident Student Supervisee Supervisor Teammate Unknown Other (Select One)	♦ Other (Please Specify)

	If you are able, please describe the person you presume is primarily responsible. Provide information that would distinguish this person from others, e.g. describe their clothing, shoes, jewelry, hair (including facial hair), approximate age, body type, any unique features like tattoos or scars, and if they possessed a weapon.

	♦ Do you know the identity of anyone involved in this incident (e.g. perpetrator, target, witnesses, accomplices, etc.)?
Involved Parties	Yes No Don't Wish to Disclose (Select One)

Acknowledgement and Submission

	♦ Acknowledgement
Acknowledge	I acknowledge that the information I provided in this report is accurate and truthful to the best of my knowledge.

	♦ Password ♦ Re-Enter Password
Password	(Passwords must be at least four(4) characters in length.)

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