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Bias/Sexual Misconduct Incident Reporting Form

Report Bias!!


As an institution of higher education, Western New England fosters learning and growth. As a community member at Western New England, you have an obligation to take an active role in fostering an appreciation for diversity and sending the message loud and clear that bias-related acts will not be tolerated. Western New England community members who feel they have been the target of bias (or who have witnessed a bias-related incident) may report the incident online below, or call or visit Kerri Jarzabski at 413-782-1282, Joanne Ollson at 413-782-1343, Cheryl Smith at 413-782-1542 or Public Safety at 413-782-1207, 413-782-1365 - Adam Woodrow.

  • This is NOT for 911 or Emergency Service
    Do not use this form to report events that present an immediate threat. If you require emergency assistance, please call the Department of Public Safety at 413-782-1411, or 911.

  • Your confidentiality and trust is very important to us! We will make every effort to respect your privacy. Please be aware, however, in certain circumstances involving safety or criminal action, we may not be able to guarantee anonymity.


Contact information is optional and only necessary if you would like follow-up/feedback. Please do not fill out if you wish to remain anonymous.
I choose to remain Anonymous
I choose to report my name
   
 ex: 12:30 pm
Below are categories that correspond to the types of bias incidents. Check all that apply.
TYPE OF INCIDENT
Bullying
Discrimination from campus office
Email or Internet message
Hazing
Inappropriate verbal comment
Indecency/exposure
Intimidation
Offensive classroom comment
Other - Incident
Phone harassment
Physical attack/assault
Property damage/graffiti
Pursuit/chase
Sexual assault
Sexual harassment
Threat of physical attack
Vandalism
Verbal assault
Written slur

TYPE OF BIAS
(Dis)ability
Age
Ethnicity
Gender identity/expression
Gender/perceived gender
Nationality/immigration status
Other - Type
Physical appearance
Race
Religion
Sexual orientation/perceived sexual orientation
Socioeconomic status/class
Veteran status

INDIVIDUALS INVOLVED
Please list names, gender (if known), and role in incident of all persons involved and impacted, including yourself.
Name of person(s)/ organizations involved Gender Role Phone Email Hall/Address
DESCRIBE INCIDENT
Please describe what happened in as much detail as possible.
ADDITIONAL QUESTIONS
In your opinion, how could this be resolved?
If needed, what is your preferred method for follow-up on this report?
SUPPORTING DOCUMENTATION
Additional supporting documentation may be attached below.   Maximum 12 megabytes per file
Attachments require time to upload, so please be patient after you click to submit this report.

Security Check and Submission