Workplace Bias Incident Report Form
Use this form to report a workplace bias incident, describe what happened, identify where and when it occurred, and share any evidence or follow-up preferences.
Incident Overview
Incident date and time
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Workplace location
*
Incident type
*
Racial bias
Gender bias
Age bias
Disability bias
Religion-based bias
Sexual orientation bias
Pregnancy-related bias
Retaliation
Other
People and Details
Are you submitting this report anonymously?
*
Yes, anonymous
No, include my contact details
Your name
First Name
Last Name
Your job title / department
Person(s) involved
*
Detailed incident description
*
Contact email (optional, non-identifying)
example@example.com
Contact phone (optional, non-identifying)
Please enter a valid phone number.
Format: (000) 000-0000.
Impact, Evidence, and Follow-up
Immediate impact of the incident
*
Feeling unsafe
Distressed or upset
Unable to continue working
Work interrupted
No immediate impact
Other
Witnesses or evidence details
Preferred follow-up method
*
Email
Phone
No follow-up
Safe email for follow-up
example@example.com
Safe phone number for follow-up
Please enter a valid phone number.
Format: (000) 000-0000.
Submit Report
Should be Empty: