Bias Reporting Form

Do you wish to remain ANONYMOUS for this report? *

Name

Preferred Phone Number

Email Address

Preferred form of contact

Your relationship to Simpson College? *

Other (?)

Date of Incident *

Time of Incident *

Hours

Minutes

Location of incident *

Do you know or believe you know who the person (people) responsible is/ are? *

Is the person a (choose one):

If you answered Yes to the previous question, please include the name(s) of the person/ people responsible

What is your primary concern? Select all that apply. *

Please provide all details regarding your concern *

Would you like to be contacted to provide you with additional information about your options and available resources?

What is your goal with reporting this incident?

Would you like Counseling Services notified of this incident? *

Would you like the Chaplain to be notified of this incident? *