Bias Incident Report Form

THIS REPORTING TOOL IS FOR NON-EMERGENCY INCIDENTS ONLY

FOR EMERGENCIES, INCLUDING SAFETY CONCERNS FOR MEMBERS OF OUR COMMUNITY, PLEASE CALL Pittsburgh City Police by dialing 911.

If you have been affected by or a witness to a perceived or actual bias incident, please complete and  submit this Report to the Director of Education for Inclusion or a trusted teacher, colleague, administrator. The filing of a Bias Incident  Report is 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 SEA to effectively respond to activity that negatively impacts the climate and well-being of our  school community. 

NOTE: If this is a critical case of an incident causing immediate and severe harm or a hate crime appears to have occurred, the observing party will immediately notify the Head of School who will convene the Council for Community Belonging (CCB) to determine if it’s necessary to enact the Crisis Management Protocol.

Sign in to Google to save your progress. Learn more
Email *
Today's Date
MM
/
DD
/
YYYY
What is your name?  


 *
Would you like to remain anonymous? Note: Since supportive action for the individual involved often requires comprehensive care, the Head of School and Associate Heads of School will be involved in the appraisal of bias incidents consistent with the school’s Bias Incident Report, Response, and Review Policy.
 *

Which of the following are you?

 *
Have you reported this incident to a SEA teacher or staff member? If yes, what is their name? *
Are you the affected individual? *
If no, please identify the affected individual(s), if known: *
Is the affected individual(s) a *
Date of the incident
 *
MM
/
DD
/
YYYY
Location of incident *
Do you know who caused the harm? If yes, what is their name? *
Type of Bias Incident (please select all that apply) *
Required
Suspected motivation of bias incident: Do you feel this incident occurred based on any of the following? (Please select all that apply)
Description of the Incident (please be descriptive including time of day when it happened and who may have witnessed the incident)
Would you like the Bias Incident Team to respond to this incident?   *
I affirm that the above information is true and correct to the best of my knowledge. *
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of St. Edmund's Academy. Report Abuse
Google Forms