Information about you

Name:

Please select the option that best describes your position at Queen's:
Student Faculty Staff Visitor

If you would like us to follow up on your report, please provide an email address or phone number.

Email Address:

Phone Number:

Information about the Incident

Date of Incident:
Year Month Day

Location:
Please be as specific as possible (building name, room number, cross streets, exact address etc.)

Were you targeted directly in this situation, or were you a witness/third party?
Directly Targeted Witness/Third Party

Perpetrator(s) acted
Alone In a group

Do you know the perpetrator(s)?
No Yes

Please describe the perpetrator(s):

Type of offense (you can check more than one):
verbal abuse harassment intimidation
physical assault sexual assault stalking
If other, please identify:

Perceived bias motive (you can check more than one):
race ethnicity sexual orientation religion
disability sex gender identity age
If other, please identify:

Vehicle Used in Crime:
No Yes
Make/Model:
License Plate Information:

Hate Propaganda(link to definition of hate propaganda)

Name of hate group linked to the material or graffiti, if known:

Do you have any photos, visuals, or copies of the materials?
No Yes
* If yes, do not erase or destroy this material! It could serve as useful evidence.

Description of the Incident

Please describe the incident in your own words. Please try to be as specific as possible.

Contacts

Have you reported this incident to any campus/community authorities (eg. Security, Kingston Police, etc.)?
No Yes
If yes, to whom did you report the incident?

Please explain:

Request for Follow-Up

Would you like us to follow-up on this report?
No Yes
If yes, please fill out your name, phone number or email at the top of this form.

Thank you for taking the time to complete this form.

If you have changed your mind about sending the report, you can clear off the form: