Office of the Dean of Students

Tolerance

Victim Information

Victim's UIUC affiliation (student, staff, faculty, visitor, etc.)?

If victim is UIUC student, in which college is he/she registered?

What year in school?
What is the victim's race/ethnicity?

Sex:
Age:

Incident Information

Date(s) and time(s) of incident(s)?

Location(s) of incident(s)? (check all that apply)

Residence Hall Sorority/Fraternity Classroom On-Campus

Private Certified Housing Apartment Campus Building Off-Campus Other:

Perceived Motive? (check all that apply)

Explain:

How was the bias demonstrated? (check all that apply)

Describe:

Offender Information

Complete as much information below as possible.

Is the offender known?

Yes No

Offender's UIUC affiliation, if any (student, staff, visitor, stranger)?

Race/Ethnicity:

Sex:
Age:
Nation of Origin:

Was there more then one offender?

Yes No

If answered yes, please give other offender information if known:

Relationship between Complainant/Victim and Offender

Check all that apply.

If you selected "Other," please explain further:

Witnesses

Were there any witness?

Yes No

Reports Filed

Report (if any) filed with law enforcement agencies. (check all that apply)

UIUC Police Department Urbana Police Department Champaign Police Department Champaign County Sheriffs Department Other

If you selected "Other," please explain further:

Report (if any) filed with other agency. (check all that apply)

Champaign Human Relations Commission Urbana Human Relations Commission UIUC Office for Student Conflict Resolution UIUC Legal Service UIUC Ombuds Office UIUC Office of the Dean of Students

If you selected "Other," please explain further: