Bias Incident Reporting Form

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This reporting form is for non-emergency incidents only.

If the incident is currently occurring, please contact SUPD at 512-863-1944.

If you have experienced or witnessed an alleged incident of bias, please complete this form. In addition to completing this form, you may meet directly with a staff member: Coordinator of Student Inclusion & Diversity, Pavityr Deol at deolp@southwestern.edu.

We ask for your name in order to acknowledge receipt of the report and to review the incident in a thorough manner. Anonymous reports will be reviewed, but the University’s ability to investigate and resolve these matters may be limited.

The Student Handbook defines prohibited conduct, including that related to bias, in the Student Code of Conduct found on pp. 8-9.

Please complete each field in this form for which you have the related information.

Your full name:

Your relationship to the incident:

I am a targeted student/victim

I am a friend or acquaintance of the victim

I am a friend or acquaintance of the individual who committed the act

I am a witness to the incident

I did not witness the incident

Other:

Your phone number:

Your email address:

Date of incident:

YYYY

Location of incident (be as specific as possible):

What types of identity do you believe this incident was targeting?

Race

Color

National Origin

Religion

Sex

Age

Disability

Sexual Orientation

Gender Identity

Gender Expression

Veteran Status

Other:

Who specifically was targeted (if known/applicable)?

What form(s) did the incident take?

In Person Verbal

Phone Call

Mail

Email/Text/Social Media Posting

Graffiti

Harassment

Intimidation

Vandalism of Living Space

Vandalism of Personal Property

Vandalism of Academic Building

Physical Assault with Weapon(s)

Physical Assault without Weapon

Other:

Involved Parties (bystanders, those who allegedly caused harm, those who were otherwise affected, etc.):

Description of incident (provide as much detail as possible, based on what you observed or experienced):

Additional description (based on anything you heard/overheard/believe but did not observe or experience):

Have you already reported this incident to anyone? If yes, whom?

As the University considers your report and determines an appropriate response, your suggestions are welcome. Would you like the University to respond to this incident?
*

Yes

Other:

Please describe any suggested responses to this incident:

Would you like someone from the Bias Response Team to contact you about this incident? (Please note: if you did not provide your name and contact information, we will not be able to contact you.)
*

Yes

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