GSU

Bias Incident Response Protocol

Instructions:  If you have been the subject of or a witness to a bias incident, please complete and submit this Report to the Opportunity Development/Diversity Education Planning Office at the address set forth below.  The Filing of a Bias Incident Report should be taken seriously and by submitting a Report, you are attesting that the information provided is true and correct to the best of your knowledge.  Submitting information about bias incidents is important.  It provides the notice necessary for Georgia State to accurately monitor and appropriately respond to activity that negatively impacts the diversity and well-being of our academic community.  Thank you for taking the time to complete and submit this report.

If you have any questions regarding this document, please contact the Office of Opportunity Development (ODDEP) at (404) 413-2567.

Note that fields marked with an * are required.

Bias Incident Report Online Submission
* Date and Time of alleged bias incident. (MM/DD/YYYY)
(TIME)
* Address of alleged Bias Incident: (Location)
Information about suspected perpetrator (if identity known): Names | Address | Telephone | Relationship to | Other
* Type of Bias Incident (check all that apply):







* Nature of Bias Incident (check all that apply):














(please describe below)
* Summary of Bias Incident:

Contact Information for individual reporting alleged bias incident (Complainant): Name | University Department or College | Local Address | Email address (optional)

* University status of Complainant (s): Student
Faculty
Staff
Consultant/Contractor
Visitor
Race:
Gender:
 

If you need additional support, please check this box. Someone will contact you to discuss your needs and any requests for accommodations.

Yes No
* Would you like to be contacted about the bias incident you are reporting? Yes No
*

I affirm that the above information is true and correct to the best of my knowledge.

Yes No
  Electronic Signature of Complainant (optional):