Bias/Discrimination/Harassment Reporting Forms #New Form

You may use this form to report incidents of possible bias, discrimination or harassment, including incidents such as graffiti or anonymous phone calls where the perpetrator is unknown. If you want to discuss the situation or request assistance, please call the Equal Opportunity Office at (360) 650-3307 or 711 (Washington Relay) to schedule an appointment. If the incident involves assault, damage to University property, or other potentially criminal conduct, you are also encouraged to contact the University Police Department at (360) 650-3911 (emergency) or (360) 650-3555 (non-emergency). The Equal Opportunity Office may forward this report to University Police if the incident appears to be a crime.

To report an incident, please provide information in the boxes below and click SUBMIT.

Incident Date:   Incident Time: Incident Location:

Description of incident (include information about any people known or suspected of being involved and their role). Include any details that make you believe that the incident was bias motivated, such as what was said and/or done.

Basis of Discrimination (check any that apply):
Race/Color Age --Select-- Anti-American Indian or Alaska Native Anti-Arab Anti-Asian Anti-Black or African American Anti-Native Hawaiian or other Pacific Islander Anti-White Anti-multiple racial groups --Select-- Age 18-26 Age 27-40 over 40 Years of Age     Ethnicity/National Origin Disability --Select-- Anti-Arab Anti-Hispanic Anti-other Ethnicity/National Origin Other Specify in comment box below Select Anti-Physical Disability Anti-Mental Disability       Religion/Creed Sexual Orientation --Select-- Anti-Atheist or Agnostic Anti-Catholic Anti-Muslim Anti-Jewish Anti-Protestant Anti-multiple religious groups Other (specify below) --Select-- Anti-Gay men Anti-Lesbian Anti-Bisexual Anti-LGB Anti-Heterosexual Other (specify below)     Sex (Including Gender Identity or Expression) Marital/Domestic Partner Status Unknown --Select-- Anti-Women Anti-Men Anti-Transgender Other (specify below) Veteran Status
Other Comments:
Name of Reporting Individual or Office: Date:
Campus Address: Phone: Email Address:
Would you like a confidential follow-up contact from a WWU support services staff member? Yes No
If you select 'yes', please provide contact information so that a support person can contact you.
(ex. Lesbian, Gay, Bisexual and Transgender Advocacy Council or Minority Employee Council member, or Ethnic Student Center, Counseling Center, Residence Life, or Prevention and Wellness staff)
You are not required to provide your name or other contact information, but the more information you can provide, the more helpful we can be.  If you include your name and contact information, you may be contacted for follow-up information and support.

Important Notification About Electronic Submission of this Web Form
If you would like to send this form anonymously, please be advised of the following:
Do NOT enter your WWU or other email address Enter as your email address xx@wwu.edu and the form will be sent to the Equal Opportunity Office anonymously.

Signatures and Attachments

The submitter may optionally enter their email address below. Press SUBMIT to send it. Your Email Address: