Bias Incident Reporting Form

Reporter Information

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Your full name:

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Note: IF YOU ARE CONSIDERED A MANDATED REPORTER, YOU MUST ENTER YOUR NAME IN THIS SECTION.

Your phone number:

Your primary email address:

Email address must be of a valid format.

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Note: IF YOU ARE CONSIDERED A MANDATED REPORTER, YOU MUST ENTER YOUR NAME IN THIS SECTION.

This incident involves:(Required):

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Date of incident(Required):

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Time of incident:

Location of incident(Required):

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Specific location:

Who's Involved?

Please list the individuals involved (including yourself, if appropriate or if you choose), including any witnesses, as applicable. Please provide as much information as known.

If the name/identity of a person is unknown to you, please enter "Unknown Person" as the name in this section and then describe the individual(s) in as much detail as possible below in your narrative.

Please identity all individuals involved in this incident and their roles.

Potential Roles:

Respondent – Individual who may have engaged in prohibited/harmful conduct

Affected Party – Individual who may have been impacted by the actions of the respondent(s)

Witness – Individual who may have observed the incident but is otherwise uninvolved

Reporter – Individual reporting incident/completing form; uninvolved in incident; did not witness incident

Name or Organization

Select Gender

Select Role

Phoenix ID Number

Phone number

Email address

Hall/Address

Questions

Supporting Documentation

Photos, video, email, and other supporting documents may be attached below. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

Email me a copy of this report

Reporter Information

Who's Involved?

Questions

Supporting Documentation

Submission