Bias Incident Reporting Form Bias Incident Reporting Form If you have been the subject of or a witness to a bias incident, please complete and submit this report. The filing of a Bias Incident Report should be taken seriously and by submitting a report, you are attesting that the information provided is true and correct to the best of your knowledge. Submitting information about bias incidents is important. It provides the notice necessary for the University of Tennessee, Knoxville to accurately monitor and appropriately respond to activity that negatively impacts the diversity and well-being of our academic community. *Do not use this form in the case of an emergency. If this is an emergency, please dial 911, UTPD at (865) 974-3111, or KPD at (865) 215-7000. Bias Education & Response Team (BERT) ResponseHow would you like the Bias Education and Response Team (BERT) to respond to this report?*Please SelectThis is for information only. No member of BERT should contact me.A member of BERT may contact me for further information and support.Reporter InformationName*The person completing this form is the:*Please SelectTarget of the incidentWitness to the incidentHeard about the incidentOtherOther personPlease SpecifyStudent ID*Email* PhoneIf you include your phone number, please include area code and all seven digits of the number.I LivePlease SelectOn CampusOff CampusClassification*Please SelectFirst Year StudentSecond Year StudentThird Year StudentFourth Year StudentGraduate/Professional StudentFacultyStaffVisitorHow did you learn about Bias Incident Protocol and Reporting?Please SelectFriendsStaff/FacultyResident AdvisorOtherOther SourcePlease specifyIncident ReportType of Incident/Event*(Please select all categories that apply) Bullying Damage/Destruction of Property Physical Harassment/Assault Verbal/Written Harassment Email/Online Harassment Graffiti Intimidation/Threats Vandalism Other (Please Specify) Other TypePlease specify.Nature of Bias*(Please select all categories that apply) Age Disability Economic Background Gender Gender Identity/Expression National Origin Race/Ethnicity Religion Sexual Orientation Veteran Status Other OtherPlease specify the nature of the biasThe person experiencing the bias was a:* UT Student UT Staff UT Faculty Visitor I don't know The person intimidating, harassing, and/or discriminating was a:* UT Student UT Staff UT Faculty Visitor I don't know Did anyone witness the incident? UT Student UT Staff UT Faculty Visitor I don't know Other Other WitnessPlease SpecifyDate of Incident Time of Incident : HH MM AM PM Incident LocationBias Incident Summary*Please provide a detailed description of the incident or concern using specific, concise, objective language. If slurs or derogatory language were used against you or another person, please place that language in quotes so we know that it is a part of the incident you are reporting. (Please be professional, accurate, and factual and include a description of the involved parties.)Supporting DocumentationPhotos, video, email, and other supporting documents may be attached. There is a limit of 4MB. Drop files here or Alleged incidents of harassment or discrimination are handled by the Office of Equity and Diversity. If you feel you have experienced an alleged incident of harassment or discrimination, you may file a formal complaint by clicking here.Thank you for completing the Bias Incident Reporting form. By clicking on Submit, you affirm that the above information is true and correct to the best of your knowledge.