Date this report is made (month, day,year):
*
Person providing this information:
Anonymous Enter your name *
Contact information for the person providing this information (if not anonymous):
Name:
Cell Phone:
Status of the person providing this information:
CAS Undergraduate student SBS Undergraduate Student CAS Graduate Student SBS Graduate Student Faculty Member Administrator Support staff *
I am a:
Resident student Student living in an off-campus apartment Student commuting from home where my family lives Non-student *
Relationship to the incident (Please check all that apply)*:
I am a targeted student/victim
I am a friend or acquaintance of the victim
I am a friend or acquaintance of the perpetrator (committed the act)
I am a witness to the incident
I did not witness the incident
Other Relationship (enter below)
Date the incident occurred (month, day, year):
*
What time did the incident occur:
*
AM PM *
Where did the incident occur:
Residence Hall Classroom Cafeteria Faculty Office (enter below) Administrative Office (enter below) Library Gym Lounge Student activity event Off-campus (enter where below) Other Location (enter where below) *
At what building did the incident occur:
150 Tremont Street Miller Hall 10 West St. & 10 West St. Expansion Holiday Inn Archer Building Donahue Building Fenton Building NESAD Ridgeway Building Sawyer Building One Beacon Street Off-campus (enter where below) Other Building (enter where below) *
How many people were targeted in this incident
*
Was a specific group targeted (name of group):
*
How many perpetrators were involved in the incident:
*
Please provide a detailed description of the perpetrators (including name if known, height, weight, race or ethnicity, age, student, faculty or staff, status unknown)
*
Please describe what happened in as much detail as you can including times, locations, number and names of witnesses, targeted students or groups and what makes you believe the incident was hate-motivated:
*
What types of identity do you believe this incident was targeting? (Please check all that apply)*:
Race
Color
National Origin
Religion
Sex
Age
Disability
Sexual Orientation
Gender Identity
Gender Expression
Genetic Information
Veteran Status
Other Identity (enter below)
What form(s) did the incident take? (Please check all that apply)*:
In person verbal
Telephone call
Mail
Email
Social media posting
Graffiti
Harassment
Intimidation
Vandalism of living space
Vandalism of vehicle
Vandalism of work or study space
Vandalism of personal property
Vandalism of a residence hall
Vandalism of academic building
Vandalism of administrative building
Physical assault with weapon(s) (enter below)
Physical assault without weapon
Sexual assault
Other Incident form (enter below)
Was this incident reported to anyone:
If yes, to whom was the incident reported?:
Were you satisfied with the result?
Comments:
Would you like a dean in the Student Affairs Office to contact you about this incident?:
If yes, please provide your name, telephone number, or department and email address. You do not have to enter this information to file a report:
Thank you for completing this form.
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