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Otterbein University Bias Incident Reporting Form

Bias Response Information >
Bias Incident Reporting Form >

In the event of an emergency, call 911.

Bias Response Information >
Bias Incident Reporting Form >

Incident Details
Date of the Incident(Required)
Time of Incident

: Hours

Minutes

AM/PM
Location of Incident
Please add any additional information about the location
Other Individuals/Parties/Organizations Involved
Name of Individual/Organization
Gender
Role in Incident
Name of Individual/Organization
Gender
Role in Incident
Add another Individual
- Add another Individual
Name of Individual/Organization
Gender
Role in Incident
Add another Individual Second
- Add another Individual
Name of Individual/Organization
Gender
Role in Incident
Add another Individual third
- Add another Individual
Name of Individual/Organization
Gender
Role in Incident
Please explain what happened in detail
Please explain what happened in detail
What was your role in the incident?(Required)
- Experienced incident of bias directly
- Witnessed incident of bias directly
- Incident of bias was reported to me (Faculty/Staff member)
- Heard about incident of bias (afterwards, second, third hand)
Type of Incident, please check all that apply.(Required)
- Bullying
- Cyber bullying
- Discrimination from campus office
- Discrimination from campus office
- Email or Internet message
- Hazing
- Inappropriate verbal comment
- Indecency/Exposure
- Intimidation
- Offensive classroom comments
- Offensive visual display
- Phone Harassment
- Physical attack
- Property
- damage/vandalism/graffiti
- Pursuit/chase
- Threat of assault or physical attack
- Verbal Harassment
- Written Harassment/Slur
- Other
Please Explain (Type of Incident)(Required)
TYPE OF BIAS, please check all that apply.(Required)
- Ability
- Age
- Ethnicity
- Gender identity/expression/perception
- Nationality/immigration status
- Physical appearance
- Race
- Religion
- Sexual Orientation/Perceived Sexual Orientation
- Socioeconomic status/class
- Unknown
- Veteran Status
- Other
Please Explain (Type of Bias)(Required)
Personal Contact Information
You have navigated to the personal information section of this form. Including your name on this report is completely optional. If you do not wish to provide your information this report will still be processed and investigated. Leave this section blank and submit to file this report OR complete the personal information then submit.
Your full name
Your classification
Your phone number
Your email address
Your physical address

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