Bias - Discrimination - Harassment Reporting Form

Reporting incidents is important so that you or someone you know can receive support, we can work to prevent further acts of bias, discrimination, and harassment, and we can improve the campus climate. You may use this form to report incidents of possible bias, discrimination or harassment, including graffiti or anonymous phone calls. If you want to discuss the situation or request assistance, you may complete this form or call 218.726.6827 for an appointment with an Equal Opportunity Specialist. If the incident involves assault, damage to University property, or other potentially criminal conduct, contact the UMD Campus Police. If it is not an emergency, call them directly at 218.726.7000. If it is an emergency, dial 911. One of our staff members will respond to you as soon as possible, but no longer than 24 hours. For emergencies, please dial 911. How To Complete This Form If the complainant prefers to remain anonymous, type 9999 in each of the name and contact information boxes below. However, please know that if we do not know the complainant's name and contact information (address, telephone number or email), we will not be able to follow up on her/his concern. The more information you provide, the more helpful we can be to you or the complainant. If you leave this page before submitting the report, you will not be able to return to this report to complete it. A new report will need to be completed.


255 Darland Administration Building - 1049 University Drive Duluth, Minnesota 55812 218/726-6827 Email: This form is available in alternative formats upon request. Please contact Cathy Rackliffe at the above address. (Revised 01/04/2012) The University of Minnesota is an equal opportunity educator and employer.

Never submit passwords through Google Forms.