Bias Incident Report Form

---

This form may be used to report a bias-motivated incident involving UC San Diego students, staff, or faculty. If you believe a crime has occurred or is in progress, please contact the UC San Diego Police at (858) 534-HELP (4357). The information contained in this report will be shared with the appropriate University officials involved in any subsequent monitoring, investigation, or resolution of the incident.

Date of Incident:
Time of Incident:
Have you reported this incident to other UCSD offices? If so, please list here:
Location of Incident
On Campus Off Campus Location (specify)
Type of Incident (Check all that apply)  Verbal Harassment  Physical Harassment  Online Harassment  Phone or Text Harassment  Damage to Property  Written Slur / Graffiti  Hate Symbol  Stalking  Other (specify)
Perceived Basis of Incident (Check all that apply)  Age  Ancestry  Citizenship  Color  Disability  Gender Identity  Genetic Information  Marital Status  Medical Condition  National Origin  Pregnancy  Race  Religion  Sex  Sexual Orientation  Veteran Status  Membership Affiliation  Economic Background  Other (specify)
Description of the incident:
(Maximum characters: 500) You have characters left.
How would you like the University to respond to this incident?
(Maximum characters: 500) You have characters left.
Alleged Offender Information
Name:      Check if name unknown :
Phone:      Email:
UCSD Affiliation:  Student     Staff     Faculty     Other
College: Unknown or Unselected Marshall Muir Revelle Roosevelt Sixth Warren
Victim Information
Name:
Phone:      Email:
UCSD Affiliation:  Student     Staff     Faculty     Other
College: Unknown or Unselected Marshall Muir Revelle Roosevelt Sixth Warren
Other information about the Victim:
(Maximum characters: 500) You have characters left.
Reporter Information (leave blank if you wish to remain anonymous)
Name:
Phone:      Email:
UCSD Affiliation:  Student     Staff     Faculty     Other