Bias Incident/RDPP Report Form

Date*

Person providing the information (if anonymous, leave blank)

First Last

Email

Phone

Status of person providing information*

Relationship to the incident (Check all that apply)*

Explanation of Event Relationship

Date the incident occurred

What time did the incident occur?*

:

Where did the incident occur?

If not listed above, please describe the location:

How many people were involved in the incident?

Please enter a number from 0 to 100.

Were there any witnesses to the incident? If so, please list.

Please provide the name of the person accused (if known). If not, please provide a detailed description including height, weight, race or ethnicity, gender, age, student, faculty or staff status, or unknown):

Please provide information regarding the relationship between the involved parties: witness(es), person(s) accused, and target(s):

Please describe what happened in as much detail as you can including times, locations, number and names of witnesses, targeted students or groups, and what makes you believe the incident was hate/bias motivated:

What types of identity, or perceived identities, do you believe this incident targeted? (Please check all that apply):*

Please enter details below:

What form(s) did the incident take? (Please check all that apply):*

Please enter details below:

Has this incident happened repeatedly?

Yes
No

If yes, please describe the frequency at which this has occurred:

Was this incident reported to anyone?*

Yes
No

If yes, then to whom was the incident reported?

Were you satisfied with the result?

Yes
No

Comments

Is there any additional information you would like to provide?