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Queen's University
 

Reporting Form

This reporting form was designed by the Queen's Alma Mater Society (AMS), the Queen's Human Rights Office and Queen's Security to offer community members an additional means of reporting hate activity.

If you are feeling threatened in any way, or if this is an emergency, please contact Queen's Security at 533-6111 or the Kingston Police at 911. Both services can be accessed 24 hours a day, 7 days a week, 365 days a year.

You will receive automatic acknowledgement of the receipt of your reporting form if you provide an email address. If you are requesting follow-up, a staff member of Queen's Security or the Human Rights Office will contact you as soon as the report has been read (during regular business hours: Monday to Friday, 9am to 5pm).

Confidentiality will be maintained. Please note that we have a legal obligation to respond institutionally to situations that may threaten the safety of community members.

Information about you

Name:

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:

  • building name
  • Room number
  • Cross streets
  • Exact address
  • Other

 

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.

 

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

Kingston, Ontario, Canada. K7L 3N6. 613.533.2000