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Bias Incident Reporting Form

Use this form to report a bias incident that you have either experienced yourself, or witnessed.

What is a Bias Incident?
A bias incident refers to behavior that is hostile, harassing, intimidating or discriminatory based on actual or perceived social identity or difference such as race/ethnicity, region, gender and/or disability.

(*) indicates a required field

Bias Incident Reporting Form
*Name:
You can write in "anonymous" if you do not wish to disclose your name.
Address:
City:
State:
ZIP code:
Phone number:
Email address:
Gender:  Male
 Female
 Transgender
 Other, please specify: 
*Your primary relationship with the institution:  Undergraduate Student
 Graduate Student
 Faculty
 Staff
 Clergy
 Visitor
 Unknown
 Other, please explain: 
Incident Information
*Type of bias incident: Bullying (including social media)
 Hazing
 Intimidation
 Verbal harassment (e.g. offensive comments)
 Physical attack
Property damage
Other, please specify:
*Type of bias:

 (Dis)ability
 Age
 Gender
 Nationality/immigration status
 Physical appearance
 Race/ethnicity
 Religion
 Sexual orientation
 Socioeconomic status/class
 Unknown
 Other, please specify: 
Individuals involved:  Supervisor
 Faculty
 Staff
 Stranger
 Partner
 Ex-partner
 Classmate
 Student
 Unknown
 Other, please specify: 
Location of the bias incident:
On campus (please specify):
Off campus (please specify):
 Unknown location
*Describe the nature of the bias incident:

If possible, please include the names of any witnesses.

Have you reported this incident to St. Norbert College Campus Safety?: Yes
No
Please specify if other offices have been contacted about this incident: 
*Upon receipt of this report, what do you want to happen?:  I would like to be contacted. Please note that you will need to provide your name and contact information above for us to contact you.
 I do not want to be contacted. I would like the report to be utilized by the college solely for informational purposes.
Please attach any supporting documentation. For example, image files or PDF documents.
*Declaration
  I understand that making an anonymous report of a bias incident (where I do not disclose my name), means that the information will be utilized by the institution to gain knowledge of the type of incidents that occur. In addition, I understand that the anony
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