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 Gender Male Female Is the victim(s) (check all that apply) 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
