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
Don’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
Assault
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
