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Walnut Hill Bias Incident Report Form
Do not use this form to report events representing an emergency. In the event of an immediate threat to life or property or you require emergency assistance, dial 911. If this is an urgent matter please contact the Administrator on Call (AOC) at 774.286.9513 or Campus Safety at 508.397.5759.
Full Name
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required
Email Address
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required
Phone Number
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required
What is your position, title, or grade level?
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required
Who is submitting this report?
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required
Please Select…
I am submitting this report on behalf of myself.
I am submitting this report on behalf of another individual/group who IS/ARE aware that I am doing so.
I am submitting this report on behalf of another individual/group who IS NOT/ARE NOT aware that I am doing so.
Individuals Involved
Write the name or organization involved in the incident.
Individual #1 Name or Organization
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required
Individual #2 Name or Organization
Individual #3 Name or Organization
Individual #4 Name or Organization
Match the affiliation (whether Student, Faculty/Staff, Sodexo, Campus Safety, etc) of the individual(s) listed above.
Individual #1 Affiliation
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required
Please Select…
Student
Faculty/Staff
Campus Safety
Sodexo
Parent/Guardian
Dorm Parent
Other
Individual #2 Affiliation
Please Select…
Student
Faculty/Staff
Campus Safety
Sodexo
Parent/Guardian
Dorm Parent
Other
Individual #3 Affiliation
Please Select…
Student
Faculty/Staff
Campus Safety
Sodexo
Parent/Guardian
Dorm Parent
Other
Individual #4 Affiliation
Please Select…
Student
Faculty/Staff
Campus Safety
Sodexo
Parent/Guardian
Dorm Parent
Other
Choose the option that best fits the involvement of the individual(s) listed above.
Individual #1 Involvement
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required
Please Select…
Alleged person(s) that caused harm
Experienced the bias directly
Witnessed the incident
Heard about the incident
Helping the victim or bystander complete the form
Individual #2 Involvement
Please Select…
Alleged person(s) that caused harm
Experienced the bias directly
Witnessed the incident
Heard about the incident
Helping the victim or bystander complete the form
Individual #3 Involvement
Please Select…
Alleged person(s) that caused harm
Experienced the bias directly
Witnessed the incident
Heard about the incident
Helping the victim or bystander complete the form
Individual #4 Involvement
Please Select…
Alleged person(s) that caused harm
Experienced the bias directly
Witnessed the incident
Heard about the incident
Helping the victim or bystander complete the form
Please provide the email address of the individual(s) listed in the section above, if you know it.
Individual #1 Email Address
Individual #2 Email Address
Individual #3 Email Address
Individual #4 Email Address
Incident Details
Location of Incident (if you know)
Do you know the date of the incident?*
Yes
No
Date of Incident
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required
(mm/dd/yyyy)
When did you find out about the incident?
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(mm/dd/yyyy)
Have you reported this incident to other Walnut Hill community members? If yes, please list them all:
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Type of Incident; check all that apply (did any of the following occur during the incident?).*
In person verbal
Telephone call
Mail
Email
Social media post or direct message
Text messaging
Graffiti
Vandalism
Not sure
Other
Please, specify:
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required
Type of Bias (Do you feel this incident occurred based on any of the following? Check all that apply.)*
Age
Citizenship Status
Disability
Gender
Gender Identity or Expression
Language
Medical Condition
Nationality/National Origin
Physical Appearance
Race/Ethnicity
Religion
Sexual Orientation/Perceived Sexual Orientation
Socioeconomic Status/Class
Not sure
Other
Please, specify:
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required
Please provide a detailed description of the incident/concern using specific and concise language. Also, please provide any additional information that may be helpful.
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required
Based on the details you included above, please describe your most immediate needs or concerns regarding this issue.
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Are there key supports you would like notified or updated related to this incident? Check all that apply.*
Parent/Family
Advisor
Dorm Parent
Affinity Group Advisor
Specific Faculty/Staff Member
Specific Student
None
Please specify which faculty/staff member
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required
Please specify which student
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List any other supports you would like notified.
Please attach any supporting documentation that you think is relevant (e.g., texts, email messages, pictures, social media).
Max file size: 10 MB
Please send a confirmation email to the address below: