Provide specifics of date, time and location of incident including building, floor number of building, room number or address. If the incident occurred in association with a specific department, please also list that information below.

Share any specific information regarding the person(s) involved in the incident you are referring including their role (alleged perpetrator, victim/target, witness, other) and their affiliation to Samaritan. If their identity is not known, please describe with any information you have.

Describe each incident of bias separately. For each incident provide the following information: 1) date(s) the action occurred; 2) name of individual(s) involved; 3) what happened; 4) witnesses (if any); 5) why you believe the action was bias, and 6) how this conduct impacted you.

Examples may include comments, conduct, gestures, markings, physical injuries, property damage, etc. If known, please share any information you have about individuals and/or groups involved with incident.

What type of response would you like to see as a result of reporting this incident?