Bias Motivated Incident / 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 (Required)

/ /

Location of Incident (Required)

In a campus building
Outside, on campus grounds
Parking lot/structure
At a campus event
Off campus
Other

Location Description

Such as the building or parking lot the incident occurred in.

I believe the motivation of this incident was (Mark all that apply)

Race

Ethnicity/National Origin

Gender

Religion

Sexual Orientation

Gender identity/expression

Disability

Age

Other

Additional motivation description

Relationship of victim to offender (Required)

*An acquaintance is someone the victim would define as "not a stranger" and is in some way known to victim

Stranger
Known person/acquaintance*
Unknown relationship

The incident was (Mark all that apply) (Required)

Verbal comment

Written/drawn

Vandalism

Verbal intimidation

Physical intimidation/assault

Physical injury

Retaliation

Other

If other please specify

Number of offenders

The incident was directed at

Me
Other People
Both

Has this incident been reported to another UW Oshkosh office?

Yes
No

If yes, which office?

Is there any physical evidence?

Yes
No

Was alcohol and/or other substance involved?

Victim

Yes
No
Unknown

If yes list substance

Offender

Yes
No
Unknown

If yes list substance

If weapon involved, type of weapon

If injury sustained, type of injury

Did victim receive medical care?

Yes
No

If medical care was administered, where?

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.

Yes
No

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

Name

Gender

Age

Race

Address

Phone

Phone #2

Victim requests confidentiality

Yes
No

Alleged Offender

Name

Gender

Age

Race

Address

Phone

Phone #2

Other offenders?

Yes
No

Alleged Offender #2

Name

Gender

Age

Race

Address

Phone

Phone #2

Person completing form, if not the victim

Name

Phone

Phone #2

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