Report a Bias/Discrimination Incident - Rainbow Alliance

Incident Report Form

If you observed or were involved in an incident of bias, discrimination, or harassment related to LGBTQ issues or perceived sexual orientation or gender identity/expression, we would like to hear about it. Any reports here are subject to the same confidentiality promises explained on our Contact a Mentor page.

If an incident is in progress, do not use this form - dial 911 for police/ambulance if needed or for Campus Safety x3299 (920-403-3299). If this is a crisis situation, dial 1-866-4-U-TREVOR (1-866-488-7836) or see our other resources.

We do not pass this information along to Campus Safety without your permission or unless we believe that you or others are in imminent danger. You are encouraged to report all incidents to Campus Safety Silent Witness in addition to the LGBTQ Ally Program.

This color and the * symbol indicate a required field

This color and the absence of a * symbol indicate an optional field

Section 1: Contact Information
Name (recommended):
Have you attended an LGBTQ (Safe Zone) Ally Training Session at St. Norbert and signed the Ally Pledge?	Yes
Campus Role: (Faculty, Staff, SNC Undergraduate Student (class year), SNC Graduate Student, or Other Guest)
E-mail address (recommended):	If you have an SNC email address, please enter it.
Phone Number:	Check this box if we can leave a voicemail message Green Bay/De Pere area local numbers preferred
Section 2: Communication Preferences
*Preferred contact method:
Should an LGBTQ Ally Mentor contact you to follow up?	Yes!
*Reply to this request preferred:	If you need emergency/crisis support, do not use this form - see our resources page
Section 3: Incident
*Type of Incident:
Have you reported this incident to Campus Safety?	Yes Campus Safety Silent Witness form
Date of incident:	Check if this is an estimate.
Offender description:	Name if known, age, appearance, etc.
*Incident Description/Narrative: