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Bias Motivated Incident or Crime Reporting Form

Purpose: The purpose is to track the nature of bias motivated incidents on and off the UW Oshkosh campus in an effort to prevent future behaviors and to help maintain a positive learning, living and working environment within our community. Examples may include but are not limited to the use of degrading language or slurs, spoken or written directed at woman, men, gays, lesbian, racist, anti-semitic, etc. Incidents that rise to the level of a crime should also be reported to University Police. This form does not take the place of reporting a crime to law enforcement.

Date and Time the incident occurred
/ /   :
Location of Incident






I believe the motivation of this incident was (Mark all that apply)
Relationship of victim to offender *An acquaintance is someone the victim would define as "not a stranger" and is in some way known to victim



The incident was (Mark all that apply)
The incident was directed at



Has this incident been reported to another UW Oshkosh office?


Is there any physical evidence?


Was alcohol and/or other substance involved?
Victim



Offender



Did victim receive medical care?


Do you wish to speak to the Victim Advocate? The Campus Victim Advocate provides you with support and information about your legal and disciplinary options. Advocates can attend medical or legal appointments with you, speak up for your rights in any community or campus actions you might choose to pursue; provide you with ongoing support and information, and help with "safety planning", such as filing restraining or no-contact orders and making changes in your residence hall or classes to avoid contact with the person who hurt you.


If yes please include at least name and contact information below.

Anonymous reporting is permitted, but is discouraged.  A report submitted anonymously will be reviewed and kept on file.  Any follow-up on anonymous reports will be done at the discretion of the Office of the Vice Chancellor for Student Affairs/Dean of Students.

Please complete if known

(All information is optional, however, confidential reporting of identifying information is encouraged to allow the University to best address the problems identified)

Victim
Victim requests confidentiality


Alleged Offender
Other offenders?


Alleged Offender #2
Person completing form, if not the victim
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