Bias Report

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Bias Report

Name of Victim «

Address «

Room # «

Phone «

ID# «

Year «

Campus Affiliation

Victim Classification

Race/Ethnicity

Gender

Sexual Orientation

Your Name

If you are not the victim

Relationship to Victim

If you are not the victim

Accused Information

Number of Persons Involved

Name(s)

If Known

Accused Classification

Accused Gender

Race/Ethnicity

Accused Person #1

Accused's Affiliation

Choose all that apply

Details reguarding affiliations

If any list here

Relationship to Victim

Of Accused

Specify if Other

From above

Did anyone witness the event

Yes

How many?

If above is selected

Event Information

Date of Incident «

Time of Incident «

Inicident Loaction «

Select all catergores which apply to the event

If any

Detailed Description of Incident «

Please include all pertinent facts, behaviors, comments, gestures, markings, clothing, or distinguishing characteristics

What was the motive for the incident «

What bias do you feel was the cause of the incident?

Other

Please Specify if other was chosen above

Was anyone physically injured? «

[ Yes ] [ No ]

Explain

If yes was chosen above

What other departments/agencies have YOU contacted?

Prior to filing this report

Specify Other

If other was selected above

Describe action(s) taken to date

Check all that apply

Specify Other

If other was chosen above

Is it ok if a Loyola official contacts you?

[ Yes ] [ No ]

Please contact me via

Contact Information

Someone else to be contacted

If you do not wish to be contacted

Additional Information

Anything you would like to provide us

Today's Date «

Fields marked with "«" are required.