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Hate- Or Bias-Motivated Incident Online Report Form

To All Members of the UCSC Campus Community :

If you believe you have witnessed, or that you have been a target of, a hate- or bias-motivated incident on campus or while participating in a University-sponsored activity, you may bring the incident to the attention of the Hate-Bias Response Team c/o the Director for Student Judicial Affairs by filling out the form below.

A copy of the campus Hate/Bias Incident Policy can be found in the UCSC Student Policies and Regulations Handbook, Appendix M located on the web at http://reporthate.ucsc.edu/policies/images/appendixm.pdf.

Information for:
Students
Staff Employees
Academic Employees

HATE- OR BIAS-MOTIVATED INCIDENT REPORT FORM

INCIDENT: Please describe the incident as specifically as you can. Include date, time, and location. If you do not know the identity of the person(s) who initiated the incident, provide as accurate a physical description as possible. Also list names of any possible witnesses.

Please indicate the category of bias (check all that apply):

Age
Creed
Ethnicity
Race
Gender
Gender Identity
Disability
Religion
Sexual Orientation
Socio-Economic Status
Veteran Status
Campus Climate Issue

Incident Information:

Date of Incident

Time of Incident

AM PM

Location of Incident

Incident Details:

Action You Are Requesting (check all that apply):
Information only, no action requested
Have the Dean of Students contact me (for student issues)
Have the College Administrative Officer contact me (for issues related to a College)
Review of possible student disciplinary action (based on Student Policies & Regulations)
Have the Associate Chancellor contact me (for staff issues)
Have the Vice Provost for Academic Affairs contact me (for faculty issues)

Please provide the following information if you wish to be contacted:

Name:
Phone:
Email:
or

For Students:

The Dean of Students (DOS) is available to provide support to members of the UCSC community. The DOS serves as an ally to, and referral source for, those students who have been targeted or who have witnessed a hate or bias-motivated incident.

The Director for Student Judicial Affairs is available to assist you with any questions you may have about your options, advice and/or referrals. You are not obligated to use your name. However, should you want Student Judicial Affairs to investigate, your name will be needed.

For Staff Employees:

The Associate Chancellor is available to provide support and assist staff members with any questions you may have about your options, advice and/or referrals. The Associate Chancellor serves as an ally to, and referral source for staff members who have been targeted or who have witnessed a hate or bias-motivated incident.

For Academic Employees:

The Vice Provost for Academic Affairs is available to provide support and assist faculty with any questions you may have about your options, advice and/or referrals. The Vice Provost serves as an ally to, and referral source for faculty members who have been targeted or who have witnessed a hate- or bias-motivated incident.