1. Optional Demographic Information

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100% of survey complete.

We will attempt to follow-up and respond to incidents reported here, but due to volume, may not be able to in every instance.

We will only use the information provided to track incidents and aggregate numbers of instances will be public, but we will not share any information provided without the explicit permission of the victim/witness. If the incident you are reporting involves literature, graffiti, etc., please take a picture or make a copy and send to research@mhrn.org

Demographic information is optional. Please leave this information blank unless you want us to be able to track the incidents according to those markers. 
 
 

* 1. Name of Person Submitting Incident Report:

* 2. Contact Information for Person Submitting Incident Report:
Please provide phone, email or mailing address depending on how you'd like to be contacted regarding this incident report.

* 3. Name of Person Who Was Victimized or Witnessed Incident:

* 4. Contact Information for Person Victimized or Who Witnessed Incident:

* 5. Gender of Victim:

* 6. Sexual Orientation of Victim:

* 7. Racial Identity of Victim:

* 8. Religious Affiliation of Victim (if any):

* 9. Age of Victim:

* 10. Date of Incident:

Date / Time
/
/
:

* 11. If there were multiple incidents, please list additional dates they occurred.

* 12. City or County Where Incident Occurred:

* 13. Type of Incident that Occurred:

* 14. Please describe the incident that occurred.
Please use as much detail as possible including using exact phrases, links, physical descriptions, license plate numbers, other people present, any organizational affiliations, any public officials involved, etc.

* 15. Have you filed a formal complaint with a government entity?

* 16. If you indicated yes above, which entity?

* 17. If you submitted a complaint, was any action taken by the entity to address your complaint?

* 18. Would you like a response to this incident report?

* 19. What type of assistance would be helpful?

REMINDER: If the incident you are reporting involves literature. graffiti, etc., please take a photo or make a copy and send it to research@mhrn.org. Sometimes the literature, symbols, and/or wording can help us determine what group or activists might be responsible.
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