Campus and Community Index: Bias Incident Report

Use this form to report incidents for the “Campus and Community Index.” The appropriate staff member will follow-up with you after you submit this report. The identity of individuals who report an incident is not included in the Index.

/ Approximate Time* :

Personal Information.  The following information will remain confidential and will not be included in any summary posted on the Index.  Please provide this information about yourself so we can follow-up with you in a confidential manner. 

Last: Email: Cell Phone:

Last   Email   Cell Phone  

Last:  Email:   Cell Phone:  

Last:  Email:  Cell Phone:  

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