Harassment, Bias, Retaliation, Discrimination, Hazing Report Form

This form is to be used to report incidents, issues, behaviors relating to harassment, bias, retaliation, discrimination, and hazing. This reporting mechanism is not intended to circumvent or replace any collectively bargained grievance procedure, student grievance processes, or other complaint avenues either inside or outside the State system. To the extent possible, information contained in this report may be maintained confidentially. After submitting this form, you will receive an acknowledgment of your submission from one of our staff as soon as possible. Updated: 03/20/2024

Reporting Individual's Information

Status of Person Reporting Incident or Issue:

Your First Name

Your Last Name

Your ethnicity/race

Please select all that apply

Your gender

Please select all that apply.

Student/Employee ID Number

If applicable

What Bates Technical College program are you associated with?

Put "NA" if not applicable.

Would you like a representative from the college to contact you for follow up?

Incident Description

Date of Incident

Status of the Subject of this Report

Time of Incident

Indicate the approximate time in which the incident occurred. Please indicate AM/PM.

Location of Incident (Campus)

Location of Incident (Room/Building)

Please list the building or room number where the incident occurred. If it occurred outside, please indicate the approximate location (example: parking lot, around the main building, or portable.)

The incident/issue/behavior is believed to be:

The incident is believed to have occurred because of:

Incident Categories

Description of Incident/Issue

Include who did what, to whom, when, where and reference to any policy or procedure violations; if known.

What efforts, if any, have already occurred to resolve the complaint?

Was this incident reported to any college employees?

Yes

Was campus security notified?

Yes

Number of Alleged Perpetrator(s)

Please indicate the number of individuals perpetrating the harassment/discrimination/retaliation. If unknown, indicate "I don't know" in the field below.

Gender of Perpetrator(s)

What is the relationship of the alleged perpetrator(s) to the victim(s) of this incident?

If an international student (on a visa) was involved, please indicate which country they are from.

Possible Witness(es)

Include: Name/Phone Number/Email/Address & role (observer, student, teacher, other).

Were there any witnesses to the incident?

In your opinion, how might Bates Technical College address this matter?

File Upload

Please add any supporting documents or photos here.

Drop your files here

Send me a copy of my responses

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