0% Reporting Person * Reporting Person (indicate victim or witness) * Reporting Person (indicate victim or witness) * Gender * Gender * - Select -WomanManNon-binaryTransgenderIntersexPrefer to self-describePrefer not to disclose Sexual Orientation * Sexual Orientation * - Select -HeterosexualBisexualGayLesbianPrefer to self-describePrefer not to disclose Ethnicity * Ethnicity * - Select -American indian or Alaska NativeAsianBlack or African AmericanHispanic or LatinoNative Hawaiian or Other Pacific IslanderMiddle Eastern or North AfricanWhitePrefer to self-describePrefer not to disclose Religion * Religion * - Select -ChristianityJudaismIslamBuddhismHinduismAtheistsAgnosticsOther Do you have a disability? * Do you have a disability? * - Select -YesNoPrefer not to disclose Phone number * Phone number * Address * Address * City * City * State * State * - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP Code * ZIP Code * Email Email Gender Identity * Gender Identity * Sexual Orientation * Sexual Orientation * Ethnic Identity * Ethnic Identity * Other religion * Other religion * Bias or Hate Incident * Category of Hate/Bias Incident * Category of Hate/Bias Incident * - Select -DisabilityEthnicityGenderGender IdentityRaceReligionSexual OrientationOther Date of Incident * Date of Incident * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20222023202420252026 Time of Incident * Time of Incident * Hour Hour123456789101112 : Minute Minute000102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859 am pm Address * Address * City * City * State * State * - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP Code * ZIP Code * Other * Other * Incident Report * YesNo Was the incident reported to Human Rights Coalition or another organization/community group? * Was the incident reported to Human Rights Coalition or another organization/community group? - Yes Was the incident reported to Human Rights Coalition or another organization/community group? - No Was the incident reported to the Middlesex District Attorney's Office? * Was the incident reported to the Middlesex District Attorney's Office? - Yes Was the incident reported to the Middlesex District Attorney's Office? - No Was the incident reported to the police? * Was the incident reported to the police? - Yes Was the incident reported to the police? - No Were charges filed? * Were charges filed? - Yes Were charges filed? - No Is there a suspect? * Is there a suspect? - Yes Is there a suspect? - No Name of the organization * Name of the organization * Organization's Contact * Organization's Contact * Police Department/Agency * Police Department/Agency * Police Department/Agency Contact Person * Police Department/Agency Contact Person * Police Department/Agency Address * Police Department/Agency Address * Police Department/Agency Phone Number * Police Department/Agency Phone Number * Reporting Party's Name * Reporting Party's Name * Reporting Party's Address Reporting Party's Address Reporting Party's City Reporting Party's City Reporting Party's State Reporting Party's State Reporting Party's ZIP Code Reporting Party's ZIP Code Reporting Party's Phone Number * Reporting Party's Phone Number * Charges * Charges * Describe the charges Suspect's name * Suspect's name * Suspect's Date of Birth Suspect's Date of Birth Suspect's Address Suspect's Address Suspect's City Suspect's City Suspect's State Suspect's State Suspect's ZIP Code Suspect's ZIP Code Media Coverage? * - Select -YesNo Please explain what happened: * Write any additional information Attachments - including police reports * Files must be less than 5 MB.Allowed file types: gif jpg jpeg png pdf doc docx. Leave this field blank