Bias Incident Reporting Form

What are bias incidents? Bias incidents can take place anywhere, and are the result of either intentional or unintentional conduct that causes harm to individuals or groups because of their race, gender, national origin, sexual orientation, religion, sex, ethnicity, age, or disability or socioeconomic, marital, or veteran status. The harm may come in various forms, such as threats, harassment, discrimination, stereotypes, intimidation, degradation, and microaggression.

Please use this form to report any incident of bias involving a CEBT staff member or client. You are not required to provide your name or contact details. Please know that if you do share your identity, you are protected by federal and Ohio laws against any form of retaliation for reporting the incident.

When you submit this form, your report is reviewed by our Bias Response Team, consisting of Monika Mendels and Amanda Groves Kopchak, within a few business days. If you share your own information, a team member may contact you to offer support, ask follow up questions, and discuss possible next steps.

Depending on the nature of the incident, the report may be referred to the Diversity Committee or Management if a potential policy or legal violation is identified. Information from reports is treated as private and is shared only with individuals who need it to provide support, review potential policy concerns, or address broader climate issues.

Submitting a bias report does not automatically start a disciplinary process, but it may lead to one if the behavior appears to violate applicable policies. If the report does not rise to a policy violation, the response may focus on education, climate interventions, or supportive measures rather than formal discipline.

Please answer N/A in any fields you don’t want to answer. If you can’t recall a precise date, please pick the first day of the month when the incident occurred.

This field is for validation purposes and should be left unchanged.
Do you want this report to be confidential?(Required)


Date you learned about the incident(Required)



Date of incident(Required)



Time of incident

:


Name of the person whose behavior is the subject of this report(Required)







Have you reported this incident to anyone else?(Required)


If so, to whom did you previously report the incident?







Location may include communications channels such as email, videoconference, etc.
Type of incident (select all that apply)(Required)











What parts of identity do you think may have been impacted or targeted, or what type of bias do you think may have occurred, in this incident?(Required)











As your report is considered, your suggestions are welcome. Would you like the Bias Response Team to respond to this incident?(Required)



Your name (You may provide your name and request that it be held in confidence as the inquiry goes forward.)
If you request that your identity remain confidential, the person handling the inquiry will do so to the extent practicable and permitted by applicable laws. CEBT’s ability to investigate allegations of misconduct and to take corrective action may be impeded if your identity is not provided to the person responding to the complaint. Depending on the nature of the allegations(s) raised (e.g. unlawful discrimination or sexual violence), conducting a fair and complete investigation may require that the full details of the incident, including your identity be shared. In those instances, all parties will be advised of CEBT’s policy against retaliation for making complaints.







Thank you for taking the time to complete this form. We recognize that sharing this information can be difficult, and we appreciate your willingness to do so. Please know that we take incidents like this very seriously.