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Public Safety
Bias/Sexual Misconduct Incident Reporting Form
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
Your full name:
Your title:
Your phone number:
Your email address:
Your physical address:
Your role:
===[PLEASE SELECT ONE]===
Experienced it (as target of bias)
Witnessed it (attended, but not target of bias)
Reported to me (as staff/student)
Heard about it (later, afterwards)
Urgency of this report:
N/A
Urgent
Not Urgent
Date of incident:
Time of incident:
ex:
12:30 pm
Location of incident:
===[PLEASE SELECT ONE]===
Alumni Healthful Living Center
Bellamy Road (14)
Bellamy Road (24)
Bellamy Road (49)
Bellamy Road (Res)
Berkshire
Boiler Building
Breck Place
Breckwood Circle
Campus Center
Campus Utilities Building
Center for the Sciences
Churchill
Commonwealth
D'Amour
Deliso
Emerson
Evergreen
Franklin
Gateway Drive
Golden Bear Pavillion
Golden Bear Stadium
Hampden
Herman
La Riviere
Law School
Legal Clinic
Not Applicable (N/A)
Outside Areas
Park Lane
Plymouth
Public Safety Building
Rivers Memorial
Sleith
Southwood
Timber Lane
University Commons
Valley Road (12)
Valley Road (20)
Valley Road (28)
Valley Road (44)
Valley Road (Res)
Welcome Center
Wilbraham
Wilbraham Road (1260)
Wilbraham Road (1268)
Windham
Specific location:
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
========
Male
Female
Transgender
Organization
Unknown
========
Impacted person
Witness
Submitter
========
Male
Female
Transgender
Organization
Unknown
========
Impacted person
Witness
Submitter
========
Male
Female
Transgender
Organization
Unknown
========
Impacted person
Witness
Submitter
========
Male
Female
Transgender
Organization
Unknown
========
Impacted person
Witness
Submitter
========
Male
Female
Transgender
Organization
Unknown
========
Impacted person
Witness
Submitter
========
Male
Female
Transgender
Organization
Unknown
========
Impacted person
Witness
Submitter
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?
===PLEASE SELECT ONE===
Phone
Email
Personal visit
Do not contact me
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
To submit the form and to prevent SPAM please take the test below.
Public Safety
Need To Know
Police Services
Emergency Planning and Response
Clery Act and Title IX
Crime Prevention
Bias/Sexual Misconduct Incident Reporting Form
Register For Defensive Driving Course