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.
Reporter Information:
Is the person making this report the victim?  Yes No
If you are not the victim, please tell us a little bit about yourself.

What's your real name?
Your city:
Reporter's Phone:
Your email address:
Please provide an email address where it is safe to contact you.
Relationship to victim:
Please identify if "other":
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.
Victim's Age:
ZIP Code:
Gender identity:
Sexual Orientation:
Please specify if other ethnicity:
How many other victims?
How many were males?
How many were females?
Sexual Orientation(s)
Date of incident:
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:
Type of Location:
Please specify location if other:
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:
Please specify if other:
Briefly describe what happened:
Were there any injuries?
Medical Attention?
For the next 3 questions, please give a short explanation of how the victim suffered in the following areas:
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:
Please specify if other:
In this section you will tell us about the person(s) who caused this hate incident.
Was the offender alone or acting with a group?: Alone  Group
Please answer the following questions even if there was only one offender.
How many were in the group?
How many were male, how many female?
Please specify if other ethnicity:
Please give approximate ages, if known.
How were they related to the victim?
Was the offender part of a hate group? Yes  No  Not sure
Describe as much as you can about the offender(s),
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.) 
 If police were not contacted, why not?

If yes, how did they respond?

To whom else have you reported this incident?

How did public officials handle your reports, if given?

Have you or the has the person you report about been the victim of violence or harassment before?

Yes No n/a


Why are you reporting this incident?

How would you like us to help you now?  What do you need?
If we need more information, may we contact you?

If you would not like us to contact you directly concerning this incident, may we contact someone else?

Yes No
Please identify, if other:
Permission to Release: Is acceptable to you for us to publish the information given in an ANONYMOUS way? 
Yes No