Bias Incident Reporting Form

Reporting Forms are for Non-emergency Incidents Only

FOR EMERGENCIES, PLEASE CALL
Penn Police: 215-573-3333 or 511 from a campus phone
Counseling and Psychological Services: 215-898-7021 option #1
University Help Line: 215-898-HELP (898-4357)

Every effort will be made to evaluate your report promptly, however, the timing and manner in which Penn addresses the report will depend upon the information provided and whether you wish to remain anonymous. Penn does not guarantee it will respond to reports. This form may be used to report incidents of bias involving Penn students, faculty, or staff. Please complete one form per incident.

You are not required to provide your name or contact information. Confidentiality will be maintained to the extent possible. However, the information contained in this report will be shared with appropriate University officials involved in any subsequent monitoring, investigation, or resolution of the incident. Penn takes the reports made through this site seriously. Please make your report as detailed as possible.

Do you wish to remain anonymous?

If you wish to remain anonymous, please ensure that the auto-fill is disabled on your web browser. Please close your browser after you have submitted the form.

In addition to, or instead of completing this form, you may contact one of the University’s confidential resource offices for advice and support.

Date you learned about the Incident

Name of the Respondent (person whose behavior is the subject of this report) and the School/Division/Department with which they are affiliated:

Date and Time of Incident

Have you reported this incident to other Penn offices? If so, please list them below:

Location of Incident

Please provide the name of the location or describe it below.

Type of Incident. Select all that apply:

Please describe the type of incident in the text area below

Basis of Incident. (Why do you believe this incident occurred?) Check all that apply.


Age	Age
Ancestry/National Origin	Ancestry/National Origin
Citizenship Status/Immigration Status	Citizenship Status/Immigration Status
Disability	Disability
Sex/Gender	Sex/Gender
Gender Identity or Gender Expression	Gender Identity or Gender Expression
Socioeconomic Status	Socioeconomic Status
Race/Ethnicity	Race/Ethnicity
Religion	Religion
Sexual Orientation	Sexual Orientation
Political Views or Affiliation	Political Views or Affiliation
Veteran Status	Veteran Status
Other	Other

Please describe the basis for the behavior in the text area below

Description of the incident (Please provide as much detail as possible):

As the University considers your report and determines an appropriate response, your suggestions are welcome. Would you like the University to respond to this incident?

Please describe any suggested responses below.

You may provide your name and request that it be held in confidence as the inquiry goes forward. If you request that your identity remain confidential, the person handling the inquiry will do so to the extent practicable and permitted by University policy and applicable laws. Penn’s ability to investigate allegations of misconduct and to take corrective action may be impeded if your identity is not provided to the person responding to the complaint. Depending on the nature of the allegations(s) raised (e.g. unlawful discrimination or sexual violence), conducting a fair and complete investigation may require that the full details of the incident, including your identity be shared. In those instances, all parties will be advised of the University’s policy against retaliation for making complaints.

Your Information

Name

Penn Affiliation

Phone

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