Bias Incident Report Form

Bias Incident Report Form

The purpose of this form is to support MHU's efforts to maintain an inclusive campus climate by establishing a mechanism by which we respond to bias incidents. This enables MHU to track bias incidents, collect aggregate data, identify educational responses, and connect individuals affected by bias incidents. Reporting this incident does not guarantee that the biased behavior will stop, but it will educate the parties involved and the campus community on how we can best address such behavior.
By completing this form, you are acknowledging:
- The information that you provide will be received by a member of the Bias Incidents Response Team and forwarded to the appropriate non-confidential reporters for preliminary investigation.
- Any incident involving possible Title IX incidents will be forwarded directly to the Title IX Coordinator for preliminary investigation.
If this is an EMERGENCY situation, call 911 or MHU security at 828 689 1230. Do not use this form as a substitute for reporting events that present an immediate threat to health or safety.
Please select one:

YES, I would like to complete the form for preliminary investigation.NO, I want to speak with a confidential reporter such as the University Chaplain, University Assistant Chaplain, Director of Medical Services, or someone from Campus Counseling who can assist me with the decision-making process.

Here is a list of confidential report personnel at MHU available to speak with you.

University Counselors: counseling@mhu.edu 828-689-1196

Phillip Brantley, Director of University Counseling Services phillip_brantley@mhu.edu 828-689-1196

Renee Sprinkle, Wellness Center, renee_sprinkle@mhu.edu 828-689-1243

Dr. Jennie Matthews, Title IX Coordinator, jmatthews@mhu.edu 828-689-1197

Stephanie McLeskey, Chaplain, smcleskey@mhu.edu 828-689-1299
Date of incident*

MonthDayYear
Date
Location of incident*
Please be as specific as possible and you feel comfortable
What do you feel this incident was motivated by? (Check all that apply)*

AgeDisabilityGender (identity or expression)Marital statusNational originPhysical appearanceRace or ethnicityReligionSexual orientationSocioeconomic statusVeteran statusOther
Please note that this report may indicate a Title IX violation and shared with appropriate personnel. In addition to making this report, please consider resources and grievance procedures outlined here: https://www.mhu.edu/campus-life/support-resources/title-ix/
Please note that this report may indicate an ADA violation and be shared with appropriate personnel. In addition to making this report, please consider resources and grievance procedures outlined here: https://www.mhu.edu/campus-life/support-resources/disability-services/
Please list the individuals involved (including yourself, if appropriate or if you choose) and provide as much information in the listed fields as you can. Witnesses should also be identified here.
Please provide a detailed description of the incident or concern. Tell us in your own words what happened and how you were involved or found out about the incident.*
Were police or other law enforcement agencies contacted?*

YesNoUnknown
Did the target of the bias-related behavior seek medical attention?*

YesNoUnknown
Has any MHU employee been notified of this incident prior to this report?*

YesNoUnknown
Whom has been notified?*
Photos, video, email, text, campus safety report, and other supporting documents may be attached below. Attachments require time to upload, so please be patient after you click to submit this report.

Click to add supporting documentation, if any

Cancelof
Reporter Information

Although not required, please note that if you choose to make this report anonymously, our ability to respond to the incident you report will be limited. Anonymous reports also limit our ability to provide you with support and resources that might be helpful to you in the future. With regard to any information you choose to provide, your confidentiality and trust is very important to us. We will make every effort to respect your privacy. Please be aware, however, in certain circumstances involving safety or criminal action, we may not be able to guarantee complete anonymity.
Your name

First NameLast Name
MHU affiliation*
Please note that this report may indicate a safe workplace violation and may be shared with appropriate personnel. Please consider reaching out to human resources by contacting Jennie Matthews at jmatthews@mhu.edu or 828 689 1197.
Would you like to be contacted regarding this report?*

YesNo
What is your preferred method of contact? (Phone number and/or email address)*
Should be Empty:

Bias Incident Report Form

Reporter Information