Bias Reporting Form Do you wish to remain ANONYMOUS for this report? - Select -YesNo If you want Simpson College to know your identity, please complete the following: Name Preferred Phone Number Email Address Preferred form of contact Your relationship to Simpson College? - Select -StaffFacultyStudentOther (?) Other (?) Date and Time of Incident Date and Time of Incident: Date Date and Time of Incident: Time Location of incident Do you know or believe you know who the person (people) responsible is/ are? - Select -YesNo Is the person a (choose one): - None -StaffFacultyStudentOther (?) 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. BiasDiscriminationDiscriminatory HarassmentMicroaggressionRacismRacist Conduct Bias – preconceived thoughts about a person or group; prejudice or preference, especially one that interferes with impartial judgment. Biases can be conscious (explicit) or unconscious (implicit). Discrimination – Unequal treatment of members of various groups based on race, gender identity, sexual orientation, social class, ability, religion, age, or other protected classes. Discrimination can occur in but is not limited to the provision of services or opportunities. Discriminatory Harassment - Discriminatory harassment refers to the verbal or physical conduct that denigrates or shows hostility toward an individual on the basis of race, color, gender, national origin, religion, age, physical or mental disability, and sexual orientation, or other protected classes. Microaggression – Subtle insults/insensitivities aimed at a person or group due to their race, gender identity, sexual orientation, social class, ability, religion, age, or other protected classes. Microaggressions can be microinsults/micro assaults through actions, words, or policies. Racism – Systemic oppression by dominant groups against minoritized groups, a result of the historical exclusion of minoritized communities in policymaking, and the development of systems (education, healthcare, criminal justice, banking, etc.). Racist Conduct – Any conduct (behavior, words, actions, policies, etc.), that promotes or contributes to racism. 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? - None -You may contact meTo the extent possible, I would like to remain anonymous to involved individuals, but you may contact me Please do not contact me What is your goal with reporting this incident? - None -Reporting purposes onlyIntervention is desired/needed * Note: in this case, we request your contact information in item #2 Would you like Counseling Services notified of this incident? - Select -YesNo Would you like the Chaplain to be notified of this incident? - Select -YesNo Submit Leave this field blank