Bias and Discrimination Incident Reporting Form

Background Information
Your full name: Your full name: First Last
Your phone number: Your phone number: - ### - ### ####
Your email address:
May we contact you?
Your physical address: Your physical address:
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Date of incident: Date of incident: / MM / DD YYYY
Time of incident: Time of incident: : HH MM AM/PM
Specific Location of incident:
Questions
NATURE OF THE ALLEGED BIAS: Please check all the categories below that describe this incident. We also strongly encourage you to fully describe, in the narrative section below, all the details of the incident, including the reasons you believe the incident was motivated by bias.

NATURE OF THE ALLEGED BIAS: Please check all the categories below that describe this incident. We also strongly encourage you to fully describe, in the narrative section below, all the details of the incident, including the reasons you believe the incident was motivated by bias. Age Citizenship Color Disability Gender Identity/Expression Religion Sex Sexual Orientation Veteran Status Genetic Information Marital Status National Origin (including shared ancestry or ethnic characteristics) Parental Status Race Other/Unknown Bias (describe below)
NATURE OF THE INCIDENT: Again Please check all the types of conduct involved in this incident. Please also be sure to fully describe the incident in the section below.

NATURE OF THE INCIDENT: Again Please check all the types of conduct involved in this incident. Please also be sure to fully describe the incident in the section below. Bullying Comment in Class or Assignment Comment in Person Comment in Writing or on the Internet Comment via Email/Text Comment via Phone/Voicemail Discrimination by Faculty/TA Discrimination by Staff/Office Discrimination by Student/Group Emotional Assault/Attack Harassment Intimidation Offensive Picture or Image Physical Assault/Attack Property Damage/Destruction Pursuit/Chase Sexual Assault Sexual Harassment Stalking Theft of Property Threat(s) Vandalism or Graffiti Verbal Attack/Assault Other Incident (describe below) Other Incident (describe below)
DESCRIPTION/NARRATIVE: Please provide a detailed description of the incident/concern using specific, concise, objective language
Have you reported this matter to anyone else at SUNY Plattsburgh?
If so, who?
What would you like to see happen to resolve your complaint?
Supporting Documentation

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Bias and Discrimination Incident Reporting Form

Background Information

Questions

Supporting Documentation