Bias Incident Reporting Form

Bias Incident Reporting Form
Guided by our Statement on Community Values, VCFA strives to cultivate and support an environment that is inclusive and equitable, empowering a rich working and learning experience free from incidents of hate, bias, and discrimination within the college community.

The Community Bias Response Program (CBRP) enables the college to track bias incidents, collect aggregate data, identify educational responses, connect affected individuals with supportive resources, and to support program and department leaders. The program is not a mechanism for investigative or disciplinary action. The program does not seek to limit academic freedom and artistic expression. CBRP does not replace any of VCFA’s current procedures and protocols in place to resolve alleged violations of policies such as those regarding student conduct, discrimination, sexual misconduct, or violation of criminal law, and VCFA’s other policies and procedures take precedent over CBRP, when applicable.

If this is an emergency, please contact an emergency service listed in this contact reference. The Community Bias Response Program reviews reports during business hours on weekdays.

Your trust is important to the Community Bias Response Program (CBRP). We will maintain your privacy and confidentiality to the extent possible. All reports through the bias incident reporting form will be handled as sensitively and discreetly as possible. Information about individuals or situations and follow-up conversations will be shared only with those who have a legitimate need to know. The CBRP cannot guarantee anonymity in any circumstances.

Although we cannot guarantee anonymity or confidentiality, we will make every effort to respect your privacy. You have the option of submitting reports anonymously. However, the College's actions in response to a complaint may be limited if the complaint is submitted anonymously.

Please note the required fields are indicated with an asterisk.
Your affiliation to VCFA:*
Other affiliation:
Your association to the incident:*
Other association:
May we contact you, if necessary?*

YesNo
Please note that anonymous reporting may limit or reduce our ability to address the incident.

Reporter Information
Name:

First NameLast Name
Pronouns:
Gender:
Email:
Phone:
Your Program / Department Affiliation:*
Other Department / Affiliation:

Incident Information
Please offer your best guess if you are not sure of the exact date, time, and location.
Date / Time of Incident:*

MonthDayYear
Date
Hour MinutesAM/PM Option
Time Zone:*
Addt'l Notes on Date / Time:
Location:*
Specific location:
To your knowledge, has this incident been reported to an individual, office or program?*
To which individual, office, or program has this been reported?*

Involved Party Information
The party involved is/are:*

Individual(s)No known or identified individuals
How many individuals were involved in this incident? Please consider impacted individuals, witnesses to the incident, and the person(s) the complaint is being made against.*
If known, please list the department(s) or program(s) involved:

Individual #1
Individual #1
Name of Individual:

First NameLast Name
Pronouns:
The Individual's Role:
The Individual's Program / Department Affiliation:
Other Department / Affiliation:
Phone:
Email:
Is this person aware that you are making a report?

YesNo

Individual #2
Individual #2
Name of Individual:

First NameLast Name
Pronouns:
The Individual's Role:
The Individual's Program / Department Affiliation:
Other Department / Affiliation:
Phone:
Email:
Is this person aware that you are making a report?

YesNo

Individual #3
Individual #3
Name of Individual:

First NameLast Name
Pronouns:
The Individual's Role:
The Individual's Program / Department Affiliation:
Other Department / Affiliation:
Phone:
Email:
Is this person aware that you are making a report?

YesNo

Individual #4
Individual #4
Name of Individual:

First NameLast Name
Pronouns:
The Individual's Role:
The Individual's Program / Department Affiliation:
Other Department / Affiliation:
Phone:
Email:
Is this person aware that you are making a report?

YesNo

Individual #5
Individual #5
Name of Individual:

First NameLast Name
Pronouns:
The Individual's Role:
The Individual's Program / Department Affiliation:
Other Department / Affiliation:
Phone:
Email:
Is this person aware that you are making a report?

YesNo

Individual #6
Individual #6
Name of Individual:

First NameLast Name
Pronouns:
The Individual's Role:
The Individual's Program / Department Affiliation:
Other Department / Affiliation:
Phone:
Email:
Is this person aware that you are making a report?

YesNo

Individual #7
Individual #7
Name of Individual:

First NameLast Name
Pronouns:
The Individual's Role:
The Individual's Program / Department Affiliation:
Other Department / Affiliation:
Phone:
Email:
Is this person aware that you are making a report?

YesNo

Individual #8
Individual #8
Name of Individual:

First NameLast Name
Pronouns:
The Individual's Role:
The Individual's Program / Department Affiliation:
Other Department / Affiliation:
Phone:
Email:
Is this person aware that you are making a report?

YesNo

Individual #9
Individual #9
Name of Individual:

First NameLast Name
Pronouns:
The Individual's Role:
The Individual's Program / Department Affiliation:
Other Department / Affiliation:
Phone:
Email:
Is this person aware that you are making a report?

YesNo

Individual #10
Individual #10
Name of Individual:

First NameLast Name
Pronouns:
The Individual's Role:
The Individual's Program / Department Affiliation:
Other Department / Affiliation:
Phone:
Email:
Is this person aware that you are making a report?

YesNo

Additional Information and Documents
Is there anything else you would like the Bias Response Team to know or be aware of?
Would you like to upload additional documents (screenshots, photos, emails, etc.)?

YesNo
File Upload:

Cancelof
I certify that the information provided in this form is correct and accurate to the best of my knowledge:*

Yes, I certify that the information provided in this form is correct and accurate.
Should be Empty: