Bias Incident Report Form
Note:
If the incident(s) involves sexual misconduct,
do not
fill out this Bias Incident Report Form. If you have experiences any form of sexual misconduct, fill out an
Informal Complaint Form
and/or
Formal Complaint Form
available at
http://www.valpo.edu/titleix/
. Sexual misconduct includes but is not limited to rape, sexual assault, sexual harassment, domestic violence, dating violence, or stalking.
*
Required
Date of incident
*
-
Month
-
Day
Year
Date
Time of incident (example:11:00 AM)
*
Person completing this form is:
*
A witness to harassment
A target of harassment
Informed by target of harassment
Informed by third party
I felt the incident was motivated by (Check all that apply)
Race
Ethnicity
National Origin
Sex
Age
Disability
Sexual Orientation
Gender Identity or Expression
Religion
Veteran/Military Status
Other
Location of incident
*
Name(s) of alleged perpetrator(s)
Description of perpetrator(s)
Please describe the incident in as much detail as possible including names of all parties involved.
*
Was the incident reported to any other department on campus or to a university official?
*
Yes
No
Other
Was the incident reported to any police agency? (Check all that apply)
*
Yes, Campus Police
Yes, City Police
No
Other
Supporting documentation: Upload files such as pictures, screenshots, etc.
Select File
Cancel
of
Please list names and contact information for any relevant witnesses
Date this report was filed
*
-
Month
-
Day
Year
Date
I wish to remain anonymous (Note: If you wish to remain anonymous, the University will not be able to follow up or adjudicate the incident.)
*
Yes
No
First name (not required)
Last name (not required)
E-mail (not required)
Phone number (optional)
Year in school (not required)
If you wish to have this incident adjudicated, you must provide your name and contact information below
Note: If you would like to talk to someone in person about this incident, please contact the Office of Multicultural Programs (ext. 6769) or VUPD (ext. 5430)
Submit
Should be Empty: