This information is for internal use only, and
will not be shared with anyone. |
This form will allow you to report Hate Crimes
and Hate Incidents - even those from years ago - online. It is easy and
takes only a short while. And it is very important. |
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Is the person making this report the victim?
Yes
No
If you are not the victim, please tell us a little bit about yourself. |
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How many victims total?
If there is more than one victim, complete the following based on a primary
victim.
You will report on the other victims later. |
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Date of incident:
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Did the incident take place in the
victim's home city?
Yes
No |
If the incident took place in another
city, please list that information here. Please enter the full name
of the city (e.g., Fort Worth instead of Ft. Worth). Thank you. |
City where incident happened: |
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State: |
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Type of Location: |
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Please specify location if other: |
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An assault can
be both physical and verbal in nature. Beyond teasing, threats
and intimidation that cause you to fear for your safety may be criminal
acts. Words, symbols, and epithets that were used can be indicators
of bias and motive. |
Hold CTRL key
down while selecting to choose multiple offenses |
Type of Offense: |
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Please specify if other: |
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Briefly describe what happened: |
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Were there any injuries? |
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Medical Attention? |
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For the next 3 questions, please give
a short explanation of how the victim suffered in the following areas: |
Physically: |
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Emotionally: |
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Financially: |
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Bias is hatred,
hostility, or negative attitudes toward someone based on their race,
sexual orientation, disability, religion, or gender. Indicators
are comments, words, graffiti, recurring incidents, cruelty, or brutality. |
Bias motives: |
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Please specify if other: |
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Did you report the incident to your
local police or law enforcement? |
Yes
No |
Please indicate to which agency you
made the report
(city police, sheriff, state police, federal authorities, etc.) |
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If police were not contacted,
why not? |
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If yes, how did they respond?
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To whom else have you reported this
incident? |
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How did public officials handle your reports,
if given?
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Have you or the has the person you report about
been the victim of violence or harassment before?
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Yes
No
n/a |
Why are you reporting this incident?
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How would you like us to help you
now? What do you need? |
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If we need more information, may
we contact you? |
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If you would not like us to contact you directly
concerning this incident, may we contact someone else?
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Yes
No |
Please identify, if other: |
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Permission to Release: Is acceptable to you for us
to publish the information given in an ANONYMOUS way?
Yes
No |
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