Bias Response Team

When You Can Make a Difference

UNI Bias Incident Report Form

This report will be reviewed by the University of Northern Iowa Bias Response Team (BRT) to determine appropriate action and referral. Thank you for your time and interest in this matter. Your input will help make UNI a safer campus and community.

Incident Information
Today’s date:

Date of the Incident:

Time of Incident:

Location:

Describe the Incident:
Victim Information:
Your Name (optional):

Are you a:
Victim Witness Family member

Friend of the victim Partner/Spouse

I was informed of the result of the incident (vandalism, verbal or graffiti, etc.)
Please help us identify the victim (s) and assist them with a trained advocate or a UNI department that can help them. (Optional)

Name of the victim (optional):

Phone number:

E-mail address:

Home address:

Race:

Male Female

Is the victim (s) (check all that applies)?

UNI student UNI staff UNI faculty

Not affiliated with UNI D on’t know

What form(s) did the bias incident take? Please check all that apply.

Verbal   Mail   E-mail   Telephone/cell

Vandalism   Vehicle   Work space

Personal property   A ssault   Intimidation

Graffiti   Other

What types of identity do you believe this incident targeted?

Race   Color   National origin   Ethnicity

Immigration status   Sex

Gender/Transgender   Sexual orientation

Social/Economic class   Veteran status

Age   Religion   Disability

Other

How many people were attacked or targeted by the incident?

One two three or more

Perpetrator Information:

What identity were the perpetrators?

American Indian/Alaskan Native
Asian/Pacific Islander

Black

Caucasian

Hispanic

Multiracial
Non-Resident/International

Don't know

How many were there?

One two three or more

Were the perpetrators?

Male   Female

Student   Faculty   Staff

Other   If other, please explain:

Can we contact you about this incident? Yes No

If yes, please provide contact information.

I agree the information provided on this form is true and correct to the best of my knowledge.
Yes No

Bias Response Team

When You Can Make a Difference

BRT Members and
Campus Resources

Procedures
and Reporting

Bias Incident
Report Form

UNI Bias Incident Report Form

Please help us identify the victim (s) and assist them with a trained advocate or a UNI department that can help them. (Optional)

Is the victim (s) (check all that applies)?

What form(s) did the bias incident take? Please check all that apply.

What types of identity do you believe this incident targeted?

How many people were attacked or targeted by the incident?

Perpetrator Information:

What identity were the perpetrators?

How many were there?

Were the perpetrators?

Can we contact you about this incident? Yes No

If yes, please provide contact information.

I agree the information provided on this form is true and correct to the best of my knowledge.
Yes No

Bias Response Team

When You Can Make a Difference

BRT Members and Campus Resources

Procedures and Reporting

Bias Incident Report Form

UNI Bias Incident Report Form

Please help us identify the victim (s) and assist them with a trained advocate or a UNI department that can help them. (Optional)

Is the victim (s) (check all that applies)?

What form(s) did the bias incident take? Please check all that apply.

What types of identity do you believe this incident targeted?

How many people were attacked or targeted by the incident?

Perpetrator Information:

What identity were the perpetrators?

How many were there?

Were the perpetrators?

Can we contact you about this incident? Yes No

If yes, please provide contact information.

I agree the information provided on this form is true and correct to the best of my knowledge. Yes No

BRT Members and
Campus Resources

Procedures
and Reporting

Bias Incident
Report Form

I agree the information provided on this form is true and correct to the best of my knowledge.
Yes No