Sonoma County Human Rights Visibility Project

Reporting Form

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* 1. Who are you reporting for?

I'm reporting an incident that happened to me.

I'm reporting an incident that I witnessed.

I'm reporting an incident for someone who is unable to make their own report.

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* 2. Please indicate your zip code of residence

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* 3. Please indicate your ethnicity or the person you are reporting for (check all that apply):

American Indian or Alaska Native

Black or African American

Hispanic or Latinx

Asian or Asian American

Native Hawaiian or other Pacific Islander

Middle Eastern

European American

Please specify your cultural identity (eg, Eritrean, Filipino, Guatemalan, Iranian, Korean, etc)

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* 4. Please indicate your gender and/or gender identity(check all that apply):

Female

Male

Two Spirit

Transgender

Non-binary

Other (please specify)

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* 5. Please indicate your age

Under 18

18-24

25-34

35-44

45-54

55-64

65+

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* 6. Please indicate if any of these circumstances describe you or the person you are reporting for (check all that apply):

I am a DACA recipient

I am a farmworker

I am experiencing homelessness

I am a member of the LGBTQIA2S+ community

I am a person with disabilities

I am undocumented

I am a veteran or member of the U.S. Armed Forces

Other (please specify)

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* 7. Date of occurrence

Date / Time

Date

Time

AM/PM

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* 8. Address of occurrence

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* 9. Place of occurrence

Adult Jail

Business

Educational institution

Foster Care

Government agency

Group home

Health Facility

Homeless Shelter

Juvenile Hall

Law enforcement street patrol

Law enforcement traffic stop

Place of employment

Police Department

Public Transportation

Residence

Residential care home

Other (please specify)

Sonoma County Human Rights Visibility Project

Reporting Form

Question Title

* 1. Who are you reporting for?

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* 2. Please indicate your zip code of residence

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* 3. Please indicate your ethnicity or the person you are reporting for (check all that apply):

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* 4. Please indicate your gender and/or gender identity(check all that apply):

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* 5. Please indicate your age

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* 6. Please indicate if any of these circumstances describe you or the person you are reporting for (check all that apply):

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* 7. Date of occurrence

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* 8. Address of occurrence

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* 9. Place of occurrence

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* 10. Please choose a topic under the drop down tab that best describes your human rights incident:

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* 11. Please describe what happened.

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* 12. Please describe the impact that this had on you.