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Bias-Related Intake Form



Your Pronouns:





NYU ID (e.g. N12345678):

Role in the Incident*:

Date of Incident:

Location of Incident:



Please list the names of the involved parties*:

Please list the names of any witness/witnesses:

Please check your preferred method(s) of communication (check all that apply)*

Please check the time of day you prefer for communication*