Are You the Victim of a Hate Crime?

If you are in need of medical assistance, please go immediately call 911 or go to the nearest hospital! This form will allow you to report Hate Crime Incidents online. It is easy and takes only a short while. You may remain anonymous. If you wish to provide your identifying information, you may do so at the bottom of the this reporting page. Otherwise the information you send is completely anonymous. The information we collect from you is very important. We need to know what is happening in our community. Select "Submit" when you have completed the form or "Reset" to clear all the entries.

Is the person making this report the victim? YesNo

Victim Information:
Is there more than one victim for this incident?YesNo
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:
Name:
Address:
City:
State:	SelectALAKAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWYOutside USA
	If you are outisde the United States, please enter 00000 for the ZIP Code.
ZIP Code:
Telephone:
Email:
Gender identity:	Select GenderFemaleMaleTransgender F-MTransgender M-FOther
Sexual Orientation:	Select OrientationGay/LesbianBisexualHeterosexualQuestioningOther
Race/Ethnicity:	Select RaceAfrican AmericanArab/Middle EasternAsian/Pacific IslanderLatina/oMulti-racialNative AmericanCaucasianJewish Other

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Other victim information:

How many other victims?
How many were males?
How many were females?
Sexual Orientation(s)	SelectDifferent OrientationsGay/LesbianBisexualHeterosexualUnknown/other

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Incident details:

Date of incident:

select monthJanFebMarAprMayJunJulAugSepOctNovDecselect day01020304050607080910111213141516171819202122232425262728293031select year19971998199920002001prior to 1997 If you are reporting an incident prior to 1997, please be sure to give the correct year in the narrative.

Did the incident take place in the same city as the victim's residence? YesNo

If the incident took place in another city, please list that information here. To help us, please enter the full, proper name of the city (e.g., San Bernadino instead of San Berdoo).  Thank you.

City where incident happened:
State:	select stateALAKAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWYOutside USA
Type of Location:	select location SchoolWorkPlace of worshipStreet/Public areaHomeOther
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 are criminal acts.  Words, symbols, and epithets used can be indicators of bias.

Hold Ctrl key down while selecting to choose multiple offenses

Type of Offense:	select offense(s)Assault without a weaponAssault with a weaponAttempted assault with a weaponSexual assault/RapeVandalismHarassment/TeasingSexual harassmentThreats/IntimidationPhone harassmentBomb threatDiscriminationStalkingOnline/Internet/E-mail harassmentMultiple/Other
Please specify if other:

Briefly describe what happened:

Extent of injuries?:	select injuryNo injuries Minor injuries Serious injuries Death Unknown
Medical Attention?:	select medical attentionNo medical attention requiredNeeded but not received Outpatient or clinic servicesHospitalization Other/unknown

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:	select motiveRacist/Ethnic Anti-homosexualSexist AIDS/HIV fear Anti-transgender No apparent bias Other
Please specify if other:

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Was the offender alone or acting with a group?:Alone Group
Please answer the following questions even if only one offender.

How many were in the group?
How many were male, how many female?
Race/Ethnicity:	Select RaceAfrican AmericanArab/Middle EasternAsian/Pacific IslanderLatina/oMulti-racialNative AmericanCaucasianJewish Other
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).

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Reporting Information:

Did you report the incident to your local police or law enforcement? YesNo

Please indicate to which agency you made the report
(city police, sheriff, state police, federal authorities, etc.) 

 If not, 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 been the victim of violence or harassment before?YesNo

Why are you reporting this incident?
...please choose... Documentation only I have questions or need helpOther/unsure.

How would you like us to help you now?  What do you need?

If we need more information, may we contact you?
...please choose... No, please do not contact me Yes, it's okay to call Yes, please email meYes, only send mailMaybe later.

If you would not like us to contact you directly concerning this incident, may we contact someone else? YesNo
Please identify, if other:

The GLBCC will automatically summarize the details in this report into an anonymous narrative that is used to create awareness about hate crimes.  Is this acceptable? YesNo

If you are completely comfortable with the information you have provided in this form and it is complete to the best of your knowledge, please click the SUBMIT button below.  If you would like to clear the form and begin again, please click the RESET button.
 

Thank you.

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Your name (optional):
Your email address: (e.g.: you@aol.com)

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Last update 12.1.01