Bias-Related Intake Form

Bias_Related Intake Form

Name :

Your Pronouns:

Phone Number*

Email*

NYU ID (e.g. N12345678):

Role in the Incident*:

Date of Incident:

Location of Incident:

Please provide a detailed account of the incident*

<br />

Please list the names of the involved parties*: 
<br />
<textarea id="00N7i00000Mvmsv" name="00N7i00000Mvmsv" rows="2" /><br />

Please list the names of any witness/witnesses:
<br />
<textarea id="00N7i00000Mvmt3" name="00N7i00000Mvmt3" rows="2" /><br />

Please check your preferred method(s) of communication (check all that apply)*<br />
<select id="00N7i00000Mvmsw" multiple="multiple" name="00N7i00000Mvmsw" title="Preferred Communication">
<option value="Email">Email</option>
<option value="Phone">Phone</option>
<option value="Text">Text</option>
<option value="Virtual">Virtual</option>
</select><br />

Please check the time of day you prefer for communication*
<br />
<select id="00N7i00000Mvmt2" multiple="multiple" name="00N7i00000Mvmt2" title="Time of Day Preferred Communication">
<option value="Morning">Morning</option>
<option value="Afternoon">Afternoon</option>
<option value="Evening">Evening</option>
</select><br />

</form>

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