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 *

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

No

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)

Incident Information

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

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