Bias Reporting Form

NCMPR takes bias incident reports seriously. Please make your report as accurate, complete and truthful as possible. Every effort will be made to evaluate your report promptly; however, the timing and manner in which NCMPR responds to the report will vary depending on the information provided and whether you wish to remain anonymous.

Bias Incident and Discrimination Reporting Form

First Name:

Last Name:

Type "anonymous" if you wish to remain so.

Date of Incident: *

Who was involved in the incident? Select all that apply: *

NCMPR general member

Presenter at NCMPR event

NCMPR board member

NCMPR staff member

NCMPR exhibitor or sponsor

NCMPR event attendee not affiliated with NCMPR

Please describe the incident in as much detail as you can, using concise and objective language: *

Please remember that the timing and manner in which NCMPR addresses this report will vary depending on the information provided and whether involved parties are available for further discussion.

Select One: *

You may contact me.

To the extent possible, I would like to remain anonymous, but you may contact me.

Please do not contact me.

Please list your phone number or email address in case we need to contact you. Disregard if you selected "Please do not contact me" above.

Your Email Address:

Phone Number:

Please respond to the following: * Required Field

There are errors that need correction above