Your confidentiality is very important and every effort will be made to protect your privacy. Anonymity cannot be guaranteed in cases involving the safety of the community, those warranting criminal action and some violation of college policies. The form does allow for anonymous reporting, however, the college’s ability to respond to incidents of bias and to prevent recurrence may be limited with anonymous complaints.

Your first and last name

Your affiliation to Goucher *

Student

Faculty

Staff

Alumnae/i

Community member

Your phone number (with area code)

Your email address

Do you want to be contacted by CCET? If so, please provide your contact information above. *

Yes

Your status to incident *

I experienced the bias directly

I witnessed the incident

I heard about the incident and wanted to report it

I heard about the incident and I am helping the victim/bystander complete this form

Date of the incident *

Time of incident *

Location of incident (be specific) *

Individuals Involved

Please list names (or anonymous or unknown), and their role in the incident of ALL involved, including yourself. *

Name or organization *

Status in incident *

Alleged offender

Impacted person

Witness

Submitter on behalf of the impacted person or bystander (faculty/staff)

Submitter (heard about it)

Affiliation to Goucher *

Student

Organization

Staff

Faculty

Guest/visitor

Vendor

Incident Information

Below are categories that correspond to the types of bias incidents. Check all the apply.

Type of incident *

Bullying

Discrimination from Campus Safety

Discrimination from faculty/staff

Email or internet message

Hazing

Inappropriate verbal comment

Indecency/exposure

Intimidation

Offensive classroom comment

Offensive visual representation

Phone harassment

Property damage/graffiti

Social media harassment

Threat of physical attack

Vandalism

Written slur

OtherOther

Type of bias (perceived or confirmed) *

Age

(Dis)ability

Ethnicity

Gender

Gender identity/expression

Nationality/immigration status

Physical appearance

Race

Religion

Please describe the incident in as much detail that you can recall *

If you are human, leave this field blank.