LGBT Housing Discrimination Incidents Survey

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1. Date and Time of Incident

	MM		DD		YYYY		HH		MM	AM/PM
Date and Time of Incident	Date and Time of Incident Date and Time of Incident Month	/	Day	/	Year		Hour	:	Minute	AM or PM

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2. Location of incident

Location of incident

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3. Individual victim(s) or target group:
(Include name, address, phone, race, gender , and other relevant description.)

Individual victim(s) or target group: (Include name, address, phone, race, gender , and other relevant description.)

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4. Describe the incident:

Describe the incident:

5. Has any other agency or advocacy group been contacted
(If so, please give name )

Has any other agency or advocacy group been contacted (If so, please give name )

6. Reported to media

Reported to media Yes

No

7. Organization or individual reporting the incident:
(Name, address, telephone)

Organization or individual reporting the incident: (Name, address, telephone)

8. Witnesses if any
(Name, address, telephone)

Witnesses if any (Name, address, telephone)

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9. Would you like for the KY Commission on Human Rights to contact you?

Would you like for the KY Commission on Human Rights to contact you? Yes

No

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10. Your Contact Information

Your Contact Information Name:
City/Town:
State:
Email Address:
Phone Number:

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