This form may be used to report a bias incident and/or hate crime. The information collected on this form will help track the frequency and nature of bias incidents and hate crimes impacting students in the Suffolk University community. Online reports will be reviewed by the Dean of Students.

You may enter your name on this online form or you may report anonymously. Anonymous reporting, however, may impact the University’s ability to respond or pursue appropriate action against the alleged perpetrators.  

* indicates required field

Date this report is made (month, day,year):	*
Person providing this information:	Anonymous Enter your name *
Contact information for the person providing this information (if not anonymous):
Name:
Cell Phone:
Status of the person providing this information:	CAS Undergraduate student SBS Undergraduate Student CAS Graduate Student SBS Graduate Student Faculty Member Administrator Support staff *
I am a:	Resident student Student living in an off-campus apartment Student commuting from home where my family lives Non-student *
Relationship to the incident (Please check all that apply)*:
	I am a targeted student/victim
	I am a friend or acquaintance of the victim
	I am a friend or acquaintance of the perpetrator (committed the act)
	I am a witness to the incident
	I did not witness the incident
	Other Relationship (enter below)
Date the incident occurred (month, day, year):	*
What time did the incident occur:	*
	AM PM *
Where did the incident occur:	Residence Hall Classroom Cafeteria Faculty Office (enter below) Administrative Office (enter below) Library Gym Lounge Student activity event Off-campus (enter where below) Other Location (enter where below) *
At what building did the incident occur:	150 Tremont Street Miller Hall 10 West St. & 10 West St. Expansion Holiday Inn Archer Building Donahue Building Fenton Building NESAD Ridgeway Building Sawyer Building One Beacon Street Off-campus (enter where below) Other Building (enter where below) *
How many people were targeted in this incident	*
Was a specific group targeted (name of group):	*
How many perpetrators were involved in the incident:	*
Please provide a detailed description of the perpetrators (including name if known, height, weight, race or ethnicity, age, student, faculty or staff, status unknown)	*
Please describe what happened in as much detail as you can including times, locations, number and names of witnesses, targeted students or groups and what makes you believe the incident was hate-motivated:	*
What types of identity do you believe this incident was targeting? (Please check all that apply)*:
	Race
	Color
	National Origin
	Religion
	Sex
	Age
	Disability
	Sexual Orientation
	Gender Identity
	Gender Expression
	Genetic Information
	Veteran Status
	Other Identity (enter below)
What form(s) did the incident take? (Please check all that apply)*:
	In person verbal
	Telephone call
	Mail
	Email
	Social media posting
	Graffiti
	Harassment
	Intimidation
	Vandalism of living space
	Vandalism of vehicle
	Vandalism of work or study space
	Vandalism of personal property
	Vandalism of a residence hall
	Vandalism of academic building
	Vandalism of administrative building
	Physical assault with weapon(s) (enter below)
	Physical assault without weapon
	Sexual assault
	Other Incident form (enter below)
Was this incident reported to anyone:	Yes No
If yes, to whom was the incident reported?:
Were you satisfied with the result?	Yes No
Comments:
Would you like a dean in the Student Affairs Office to contact you about this incident?:	Yes No
If yes, please provide your name, telephone number, or department and email address. You do not have to enter this information to file a report:
	Thank you for completing this form.
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