Harassment or Bias Incident Report

IF YOU ARE DEALING WITH AN EMERGENCY SITAITON, PLEASE CALL 911 AND COMPLETE THIS FORM LATER.

This form should be used to report any event believed to have been hate- or bias-motivated and that happened to you at Macalester College or in the Twin Cities area. Your responses can be anonymous unless you chose to include identifying information on this form.

IF YOU WOULD LIKE TO REPORT AN INCIDENT IN PERSON, PLEASE CALL CAMPUS SECURITY AT 696-6555 OR THE STUDENT AFFAIRS OFFICE AT 696-6220.

 

Date of Incident

Time of Incident
 am     pm

Location of Incident (check all that apply)
 Residence Hall
 Off campus home/apartment
 Campus building
 Classroom
 Library
 Parking lot/car
 Online (e-mail, blog, Facebook, etc.)
 Other (please describe)
  

Nature of Incident (check all that apply)
 Graffiti
 Posters
 Threat of harm
 Derogatory jokes or comments based on a social identity (race, religion, sex, ability, religion, etc.)
 Notes, letters, or written message
 E-mail
 Physical force or Incident
 Other (please explain)
  

Detailed description of the Incident:

Which aspects of identity were being attacked: (check all that may apply)
 Race
 National Origin
 Ethnicity
 Immigration status
 Gender Identity
 Sexual orientation
 Social/Economic Class
 Religion
 Ability
 Other (please specify)
  

Please elaborate, if possible, as to what may have motivated this incident:

Please describe the perpetrator(s) to the best of your ability:

The person completing this form is:
 A victim of the incident
 A witness to this incident
 A friend or acquaintance of the victim who did not witness the incident
 A friend or acquaintance of the perpetrator(s) who did not witness the incident

Was this incident reported to anyone, and if yes, who?

If you would like a trained ally or staff member to contact you to follow up on this report, please enter your contact information below:

Name:

E-mail:

Phone number:

Thank you for completing this report. Your information helps us to track and respond to hate and bias on campus. Please take a minute to read over and confirm your answers before you submit them.