Bias Incident Reporting Form

Bias Incident Reporting Form

 

Thank you for completing the following survey! Your feedback is valuable as it helps provide information for evaluation and improvement of the discipline process at Bowling Green State University. You may submit an anonymous report, however we will contact you if you provide contact information. Please be honest in your responses.

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Location of incident:

 in a class
                in a campus office                 in a campus building                 while walking on campus
                 at a campus event
                in a residence hall
                off-campus
                parking lot/structure
                other
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Date incident occurred:
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I believe the motivation of this incident was: (mark all that apply)

 race
                ethnicity
               gender
               religion
               sexual orientation
               disability
               gender identity/expression
               retaliation
               age
               military/veteran
               other
 
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The incident was directed at:

               me
               other people
               both

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Has this incident been reported to another BGSU office?

              yes
              no
              I don't know

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Is there any physical evidence?

              yes
              no

 

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The incident was: (mark all that apply)

 verbal comment
                written/drawn
               phone harassment
                vandalism
                verbal intimidation
                physical intimidation
                assault

 

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First Name:

Last Name:

Address:

City:

State:

Zip Code:

Phone:

Email Address:


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Name of FIRST Violator, if known:

Address of FIRST Violator, if known:

 

Is the FIRST Violator a BGSU student, if known:

Yes
               No
               I Don't Know

 

Names of other violators:

 
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Description of the incident:

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Once submitted you will be transferred to the Dean of Students Homepage
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