City of Edina Form Center

2. Report Bias or Discrimination
4. In Emergencies
   This form is not intended for emergency purposes. If you need to report an emergency where someone is at immediate risk of harm, please call 911.
6. Making a Report
   If you feel you have been discriminated against and the discrimination occurred within the City of Edina with the last 365 days, please complete this form or contact Race and Equity Coordinator, Heidi Lee, by email at [email protected] or by phone at 952-826-1622. You can also contact the Minnesota Department of Human Rights (MDHR) by calling 651-539-1133 or toll free at 1-800-658-3704 or by email at [email protected]
8. What is the Purpose of This Form?
   The purpose of this form is to monitor to potential bias and discrimination incidents that occur within the services, facilities, and institutions in the City the Edina government. Submitting this is making the City aware of incidents and submission of this form may or may not result in criminal or city action.
9. Who Should Fill Out This Form?
   Anyone who has experienced, witnessed or learned of a potential bias incident within 365 days of form completion date.
11. What Happens After I Submit the Form?
    The submitted form is routed to the appropriate City of Edina staff member. Every effort will made to review the report promptly; however, the timing and action of the City to respond to the report will vary depending on the information provided. Submission of this form will likely result in a staff person contacting you to discuss the situation and gather additional information, so please make sure to provide accurate contact information.
15. About Person Completing This Form
17. What Happened?*

    1. I experienced a bias incident
    2. I witnessed a bias incident
    3. I learned about a bias incident
    4. I am a City Staff member who was contacted about a bias incident
19. Your Name*
20. Email Address*
    Provide a current email address that can be used to contact you.
22. Address
24. City
25. State
26. Zip Code
28. Phone Number*
30. How Would You Prefer to be Contacted?*

    1. Email
    2. Phone
34. About the Incident
36. Nature of Bias*

    Check all that apply

    1. Age
    2. Ability
    3. Coronavirus (COVID-19) Stigma
    4. Ethnicity

    1. Gender
    2. Gender Identity
    3. National Origin
    4. Race

    1. Religion
    2. Sexual Orientation
    3. Veteran Status
    4. Other
38. Other Bias*
    If you checked "Other" under Nature of Bias, please describe in a few words. We'll ask for details later in this form.
40. Bias Occurred Through*

    Check all that apply

    1. City Service: Assistance or support provided by the City
    2. City Facility: Physical location such as City Hall, a specific park, etc.
    3. City Institution: Process and policies within the City
42. Date of Incident*
    Date of Incident
    If you don't recall exactly, please take your best guess.
43. Location of Incident*
45. Type of Incident*

    1. Assault
    2. Harassment
    3. Intimidating or Threatening Behavior or Speech
    4. Vandalism
    5. Other
46. Other Type of Incident*
    If you selected "Other" for Type of Incident, please describe it in a few words.
48. Description of Incident*
50. Social Media Post or Website
    If the incident appears in or is related to a social media post or website, please provide the link (full URL) or links involved.
52. Photos or Documents from Incident
    If you have photos, documents or other files related to this incident, please upload them.
53. Another Photo or Document
    If you have photos, documents or other files related to this incident, please upload them.
55. Do you have more files to upload?

    1. Yes
    2. No
57. Upload
58. Upload
60. Other Proof or Unable to Upload Items

    If you are unable to upload a file or don't have it in digital form but would be willing to provide it to us, please check the below box. We will ask about it when contacting you.

    1. Please contact me for files I have related to this incident
62. Public Data Advisory*

    Information you provide on this form is subject to public data laws. Any public information would be released upon request.
    By completing this form, you are consenting to this information being shared with staff to determine action needed and for staff to contact you. You may choose not to provide some or all of this information, but it may limit staff's ability to assist you or address the issue.

    1. I have read and understand the Public Data Advisory
Leave This Blank:


64. 1. Receive an email copy of this form.
65. Email address

    This field is not part of the form submission.

66. Submit

* indicates a required field