First Name

Last Name

Your Email

Phone #

Your Address

Your Date of Birth

Were you involved? (Please check all that apply)
I am the VictimRelative of VictimFriend of VictimCo-Worker of VictimWitness OnlyOther (Please describe below)

Incident Information
Date of Incident

Time of Incident

Location/Address of Incident

Location Type (Please Choose)Business or StoreOnlinePlace of WorshipPrivate ResidencePublic FacilityPublic StreetPublic TransitSchoolOther

Victim Information
Same as Reporter Information

First Name

Last Name

Contact Phone #

Primary Language

Suspect/Perpetrator Information
Victim's relationship to suspect/perpetratorAcquaintanceCo-WorkerEmployer/SupervisorFriendNeighborRelativeStrangerOtherUnknown

If other, please describe

First Name

Last Name

Contact Phone #

Address

Race (if known)

Age (approximate, if known)

Type of Hate Crime / Hate Incident (please check all that apply)
Verbal/Name Calling/Written CommunicationVandalism or GraffitiPhysical AssaultRefused Service or TransportationThreats of Physical Harm or Property DamageOther (Please describe below)

Description of Hate Crime / Hate Incident
Please include as much detail as possible including what occurred before, during and after the incident as well as any specific words said or actions taken by the suspect and anyone else involved.

What bias or motivation do you believe was involved in this hate crime / hate incident? (Please check all that apply)
RaceReligionSexual OrientationSkin ColorGenderEthnicityDisabilityNational OriginOther (Please describe below)

Was anyone injured during the incident? If so, please describe below.

Was property damaged during the incident? If so, please describe and indicate the value of the property damage or cost of repairs.

Evidence
Do you have any photos, videos, documents, or other files you can provide that would assist the police department in determining exactly what occurred? If so, please upload these files below.