Community Interaction Reports Motivated by Hate/Bias

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Reporting Person (indicate victim or witness) *
Gender *
Sexual Orientation *
Ethnicity *
Religion *
Do you have a disability? *
Phone number *
Address *
City *
State *
ZIP Code *
Gender Identity *
Sexual Orientation *
Ethnic Identity *
Other religion *
Category of Hate/Bias Incident *
Date of Incident *
Time of Incident *
:
Address *
City *
State *
ZIP Code *
Other *
YesNo
Was the incident reported to Human Rights Coalition or another organization/community group? *
Was the incident reported to the Middlesex District Attorney's Office? *
Was the incident reported to the police? *
Were charges filed? *
Is there a suspect? *
Name of the organization *
Organization's Contact *
Police Department/Agency *
Police Department/Agency Contact Person *
Police Department/Agency Address *
Police Department/Agency Phone Number *
Reporting Party's Name *
Reporting Party's Address
Reporting Party's City
Reporting Party's State
Reporting Party's ZIP Code
Reporting Party's Phone Number *
Charges *
Describe the charges
Suspect's name *
Suspect's Date of Birth
Suspect's Address
Suspect's City
Suspect's State
Suspect's ZIP Code
Write any additional information
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