Bias-Motivated Incident Reporting Form

Person Reporting

As the person submitting this report, you are not required to provide names or contact information. However, it can be very helpful in following up during the investigation.

Name: (Optional)

E-mail: (Optional) answer must be an email address

Information about the Victim

Name of Victim: (Optional)

What is the victim's affiliation with the University of Illinois at Urbana-Champaign (student, staff, faculty, visitor, etc.)?

If a University of Illinois student, in which college is the victim registered?

What is the victim's race/ethnicity?

Gender:

Age: