Bias Incident Form

Please provide as much information as you feel comfortable in sharing. Your incident report can be made anonymously.

Your Name:

First

Last

Your Bluefield University ID#:

Your affiliation with Bluefield University: (Choose all that apply) *

Your phone number:

Your email address:

Date & time of incident: *

Date

Time

Specific location of incident: *

Please list all involved parties if you know them.

Do you know the name(s) of any of the other involved parties? *

Description/Narrative: *

Please indicate whether you would like to be contacted for further follow-up after submission of this form. You must make at least one selection. *

Has this incident been reported elsewhere? *

Please provide any supporting documentation that you would like us to review (pictures, files, etc.)

Click or drag files to this area to upload. You can upload up to 5 files.