JUST Door County, Inc. - Incident Report Form

JUST Door County, Inc. is seeking to document the extent and type of harassing and discriminating incidents that occur in our community.

Our purpose is to raise awareness in our community, to gather aggregate data about these incidents, and to use that data to push for meaningful change. We do not seek to name, blame, or shame any individual or place of business. While we may share the story of your experience with others in our community, to protect your privacy, we will not reveal your name or contact information, should you choose to share it with us. If you wish, you may remain completely anonymous.

Thank you for sharing your experiences with us. We are sorry if the incident you experienced or witnessed caused you discomfort or pain. We can promise you that we and many others here are committed to making Door County accountable for creating a welcoming and inclusive community for everyone who lives, works, and visits here. Thank you.

Question Title

* 1. This incident

Happened personally to me

Did not happen to me, but I personally witnessed it

Did not happen to me, but was told to me directly by the person it happened to

Did not happen to me, but I heard about it from a third-party source (grapevine, social media, mutual friend, etc.)

Other (please specify)

Question Title

* 2. Type of Incident. Check all that apply.

Physical Assault or threat of assault

Verbal abuse or threat

Sexual intimidation or innuendo

Refusal or delay of service

Name calling or use of slurs

Ridicule or justifying ridicule as "just joking"

Damage to property or vehicle or theft

Malicious communications (calls/texts/emails/social media posts or messaging)

Microaggressions

Other (please specify)

Question Title

* 3. In what Door County town/village/city did this incident occur?

Question Title

* 4. At what type of establishment did this incident occur?

Place of employment

Private home or apartment

Public or private school, college, educational institution

Public venue (state/county park, beach, highway, marina, parade, festival, etc.)

Private business (restaurant, store, hotel/motel/resort, campground, gallery, theater, etc.)

Church, congregation, fellowship, or other religious setting

Hospital, clinic, physician's office, or other medical setting

Courthouse, police station, or other government building

Other type of establishment? (please specify)

Question Title

* 5. When did this incident happen? It's OK if you don't recall the exact date.

Question Title

* 6. What personal identity was being targeted in this incident? Check all that apply.

Race

Ethnicity/National Origin

LGBTQ

Gender or Gender Identity

Disability

Age

Economic or Social Class

Immigrant or Refugee Status

Religion

Other (please specify)

Question Title

* 7. To your knowledge, has this incident been reported to someone in authority (for example, to a store manager, a supervisor, police, or other authorities)? NOTE: This form is NOT a legal complaint and will NOT be shared with legal authorities. Please contact local law enforcement if you wish to file a legal complaint.

Yes

I don't know

Other (please specify)

Question Title

* 8. Do you have a photo, video, witness statement or other corroboration of the incident that you would be willing to share with us?

Yes

I don't know

Other (please specify)

Question Title

* 9. Please describe the incident. It is your choice how many details to share, but to protect your privacy and the privacy of others, we will not reveal any names of specific people or places that you may mention.

Question Title

* 10. OPTIONAL: May we have your name and contact information (phone number/email address, etc.) to follow up with you about this incident. THIS IS ENTIRELY OPTIONAL AND WE WILL NOT SHARE YOUR NAME OR CONTACT INFORMATION WITH ANYONE WITHOUT YOUR WRITTEN PERMISSION.

Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number