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Bias Incident Report
Please fill out this form to report a bias/hate incident to The Peace Center.
We will contact you to assure that we have accurate information for reporting.
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* Indicates required question
Email
*
Your email
Your name:
*
Your answer
Your phone number
*
Your answer
Date of incident
*
MM
/
DD
/
YYYY
Location:
*
Your answer
Type of incident (please check all that apply):
cyber bullying
in-person bullying
race based
color based
religion based
national origin based
sexual orientation based
gender based
gender identity based
disability based
Please describe what you saw, heard, or found using as much detail as possible.
(please upload photo if possible)
Your answer
Have you reported the incident to your local law enforcement?
Yes
No
Clear selection
Additional comments:
Your answer
Send me a copy of my responses.
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