Campus and Community Index: Bias Prevention Report Form

Use this form to report educational/prevention efforts that have already occurred. An appropriate staff member may follow-up with you to obtain additional information before posting this educational effort to the Campus and Community Index. The identity of individuals who report an educational effort is not included in the Index.

/ Approximate Time* :

Personal Information (REQUIRED).  The following information will remain confidential and will not be included in any summary posted on the Index. Anonymous reports will not be posted on the Index. Please provide this information about yourself so we can follow-up with you, as necessary.

Last* Email* Cell Phone*

Last   Email   Cell Phone  

Last:  Email:   Cell Phone:  

Last:  Email:  Cell Phone:  

* denotes a required field