Exit

1. Optional Demographic Information

Page1 / 1
 
 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. 
 
 

Question Title

* 1. Name of Person Submitting Incident Report:

Question Title

* 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.

Question Title

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

Question Title

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

Question Title

* 5. Gender of Victim:

Question Title

* 6. Sexual Orientation of Victim:

Question Title

* 7. Racial Identity of Victim:

Question Title

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

Question Title

* 9. Age of Victim:

Question Title

* 10. Date of Incident:

Date
Time

Question Title

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

Question Title

* 12. City or County Where Incident Occurred:

Question Title

* 13. Type of Incident that Occurred:

Question Title

* 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.

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

* 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.

T