Three Rivers School District - Bias Incident Response Form 
Students and visitors use this form to report an incident of bias if it is an act of conduct, speech or expression that targets an individual or group based on their actual or perceived race/color, religion, ethnicity, national origin, gender, gender identity/expression, age, ability/disability, or sexual orientation. 

We appreciate that you are taking action and filing a report. This report is anonymous. TRSD will follow Policy ACB-AR, Title IV and any other applicable State and Federal laws when conducting an investigation. 

If you have questions about completing this form or your reporting options, please contact Stephanie Allen-Hart or Dawn Werner at or 541-862-3111. 

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Your Name (not required).  
Your Email Address (not required). 
Date of the bias incident.  *
Time of the bias incident.  *
Location of the bias incident. *
Physical space of bias incident.  *
Relationship to the bias incident.  *
Names of folks who witnessed the bias incident (students and adults).  *
Names of folks who are victims of the bias incident (students and adults).  *
Names of folks who caused harm (students and adults).  *
Please describe the facts (not opinions) of the bias incident. Please use as much detail as possible including comments, actions, conduct, gestures, markings, physical injury, property damage, hate symbol, etc. *
Please state anything else you feel we should know.  *
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