Bias Incident Reporting Form

Bias Incident Reporting Form

Ball State University students may use this form to report incidents of bias to the Office of the Vice President for Student Affairs/Dean of Students. The Assistant to the Dean, or another staff member, will contact you to set up a time to talk about this incident. If you have questions about submitting this form, please call 285-1545.

The Division of Student Affairs at Ball State plays a critical role in shaping your student experience. Our role is to be responsive. When incidents of bias occur, we offer assistance and support. Student Affairs also oversees processes that may be used to confront the inappropriate behavior of those who committed such offenses.

Date incident occurred:
Location of incident:	in a class in a campus office in a campus building while walking on campus at a campus event in a residence hall off-campus parking lot/structure other
I believe the motivation of this incident was: (mark all that apply)	race ethnicity/national origin gender religion sexual orientation disability gender identity/expression retaliation age other
This incident was directed at:	me other people both
Has this incident been reported to another BSU office?
Is there any physical evidence?
The incident was (mark all that apply):	verbal comment written/drawn vandalism verbal intimidation physical intimidation/assault physical injury
First Name
Please enter your first name.
Middle Initial
Please enter your middle initial.
Last Name
Please enter your last name.
Address Line 1
Please provide your address.
City
State
Zip
Phone
Please provide your phone number.
Email
Please provide your email address.
Name of FIRST offender, if known:
Address of FIRST offender, if known
Is FIRST offender a BSU student?
Name of SECOND offender, if known:
Address of SECOND offender, if known:
Is SECOND offender a BSU student?
Names of other offenders, if known.
Anonymous	Anonymous reporting is permitted, but is discouraged. A report submitted anonymously will be reviewed and kept on file. Any follow-up will be done at the discretion of the Office of the Vice President for Student Affairs/Dean of Students.
Description of incident:
Please use this space to provide as much detail as possible about the incident you are reporting.