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Bias Incident Reporting Form


Date of Report:

Reporter's Information:

Anonymous:

Yes No
(if no, fill out the rest of this section)

Name: (optional)

Campus Address: (optional)

Cell Phone Number: (optional)

Email Address: (optional)

How would you prefer to be contacted? (optional)

Email     Phone     Mail

If student, I am: (optional)

Hobart William Smith
(if no, skip to "If other, please specify")

Class of: (optional)

If other, please specify: (optional)

Relationship to the Incident:

Please check all that apply:

Targeted student/victim
Friend of/acquaintance of victim
Friend of/acquaintance of perpetrator (committed act)
Witnessed the incident

Other, please specify:

Incident Information:

Date of Incident:

Time of Incident:

Location of Incident:

On Campus, please specify:
Off Campus, please specify:

Number of people targeted in this incident:

Specific group(s) targeted:

Please provide a detailed description of the perpetrators (including name if known, height, weight, race or ethnicity, age, status (student, faculty, staff or unknown):

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

Check any of the following personal characteristics that you feel the perpetrators of this incident were targeting::

Age
Disability
Gender Identity or Expression
Genetic Information
Marital or Familial Status
National or Ethnic Origin
Race
Religion
Sex
Sexual Orientation
Veteran Status
Other, Please Specify:

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

In person verbal
Telephone Call
Mail
Email
Social Media Posting
Graffiti
Vandalism of living space
Vandalism of vehicle
Vandalism of work or student space
Vandalism of personal property
Vandalism of a building
Vandalism of administrative building
Physical assault with weapon(s)

Physical assault without weapon
Sexual assault
Other, Please Specify:

List any other individuals or offices to which the incident has been reported

Do you wish to take specific action?

Yes No

If yes, what actions(s) do you wish to pursue (Please check all that apply): (optional)

Facilitated conversation/mediation
Student judicial action
Criminal complaint

Additional comments or concerns

Thank you for completing this form.

Note: Please understand that under certain circumstances, the Colleges may have an obligation to act upon the information you provide even if you request that the Colleges take no action beyond recording the incident. For example, the Colleges will need to investigate situations that may threaten the saftey or anyone mentioned in this form or Hobart and William Smith Colleges' community. Alternatively, please understand that if you do not complete the form fully (or if you request anonymity), the Colleges may be limited in its ability to take action, even if you would like the Colleges to do so.