Bias Incident Reporting Form

Date of Report:
Person providing this information:  (please check) Anonymous, or
If not anonymous:
Name:
Campus Address:
Cell Phone Number:
Email Address:
How would you prefer to be contacted? (please check):
Email Phone Mail
Status of the person providing information:
If student, I am a:
If other, please specify:
Relationship to the Incident (please check all that apply):
targeted student/victim friend or acquaintance of victim
friend or acquaintance of perpetrator (committed act) witnessed the incident
Other, Please Specify: 
Date of Incident: Time of Incident:
Location of Incident:  (please check)
On-campus, Please Specify Building:
Off- campus, Please Specify Location:
How many people were targeted in this incident:
Was a specific group targeted (name of group):
How many perpetrators were involved in the incident:
Please provide a detailed description of the perpetrators (including name if known, height, weight, race or ethnicity, age, status (student, faculty, staff or unknown):
Please describe what happened in as much detail as you can including number and names of witnesses, targeted students or groups and what makes you believe the incident was bias-motivated:
What personal characteristics do you believe the perpetrators involved in this incident were targeting? (Please check all that apply):
Age Color Disability Gender Identity or Expression
Genetic Information Marital or Familial Status National or Ethnic Origin Race
Religion Sex Sexual Orientation Veteran Status
Other, Please Specify:
What form(s) did the incident take: (Please check all that apply):
in person verbal telephone call mail email
social media posting graffiti vandalism of living space vandalism of vehicle
vandalism of work or student space vandalism of personal property vandalism of a building vandalism of administrative building
physical assault with weapon(s):
physical assault without weapon sexual assault
other Incident form:
List other individuals or offices to whom the incident has been reported:
Do you wish to take specific action? Yes No
If yes, what action(s) do you wish to pursue ( check all that apply):
facilitated conversation/mediation student judicial action criminal complaint
Additional comments or concerns:

Thank you for completing this form. 

Please understand that under certain circumstances, the University may have an obligation to act upon the information you provide even if you request that the University take no action beyond recording the incident.  For example, the University will need to investigate situations that may threaten the safety of anyone mentioned in this form or the Lehigh University community.  Alternatively, please understand that if you do not complete the form fully (or if you request anonymity), the University may be limited in its ability to take action, even if you would like the University to do so.

Patrick V. Farrell speaking at commencement