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Incident Details

 
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)
 
 
(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.
 
 
(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
 
 
 
 
Where did the incident take place; Campus, Area, Location.
Where 
(Select One)
 
 
(Select One)
(Please Specify)
 
 
(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.
 
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'.
 
 
(Select One)
 
(Select One)
(Please Specify)
 
 
Have you previously reported this incident to the campus police or another University official?
Previously Reported
(Select One)
 
 
 
   

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
(Select One)
 
 
Name

 
 
Would you like to be contacted regarding this incident?
Contact Information
(Select One)
 
What is your preferred method of communication?
 
(Select One)
 
 
 
 
(Format: (###) ###-### )
(Format: username@domain.com)
 
 
 
 
 
 
 
 
 
 
Relationship
(Select One)
(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
 
(Select One)
 
 
(Select One)
 
(Please Specify)
 
 
(Select One)
 
(Please Specify)
 
 
(Select One)
 
(Please Specify)
 
 
(Select One)
 
(Please Specify)
 
 
(Select One)
 
(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
 
(Select One)
(Please Specify)
 
Do you know the identity of anyone involved in this incident (e.g. perpetrator, target, witnesses, accomplices, etc.)?
Involved Parties
(Select One)
 
Enter a list of parties in this incident.
List of Participants
 
 
  • Last Name
  • First Name
  • Role
  • Relationship
1.
  • ******
  • ******
  • ******
  • ******


 
 
First Name
 
Last Name
 
M.I.
Details
*****
*****
*****
 
 
Phone Number
 
Email
 
*****
*****
 
 
Role In Case
 
Other Role 
 
*****
*****
 
 
Relationship
 
Other Relationship 
 
*****
*****
Demographics
 
Age
 
Race/Ethnicity
 
National Origin
 
*****
*****
*****
 
 
Gender
 
Sexual Orientation
 
Religion or Creed
 
*****
*****
*****
   
 
 
Details

Please Note: If you know only a first or last name, please enter it in the appropriate box & enter 'unknown' in the other box.
 
 
 
 
(Format: (###) ###-### )
(Format: username@domain.com)
 
(Select One)
 
 
(Select One)
 
 
The following information is optional. We use it only for analytical purposes, to understand the dynamics of intolerance issues.
 
 
 
 
Demographics
(Select One)
(Select One)
(Select One)
 
 
 
 
 
(Select One)
(Select One)
(Select One)
 

Acknowledgement and Submission

 
Acknowledgement
Acknowledge
 
Password

(Passwords must be at least four(4) characters in length.)

Submit
When you submit this report, you will be issued a Report Key. Please write this information down along with your password, in a secure and private place. Neither your report key, nor your password, can be recovered, or reset once this report has been submitted.

Using the system generated report key and password, you may return to this form at any time to submit additional information, provide updates or review your submission.
   
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