Please tell us which city/state the incident took place:

City:

State:

When did the incident take place?
Date? (mm.dd.yyyy)

Please tell us who you are:
choose one Victim Witness

Type of Incident:
choose one Verbal intimidation or threat Excessive physical force Sexual assault Deadly Force False stop/search False arrest/imprisonment Seizure/destruction of property

Where did the incident take place?
Street, road, or intersection Private residence or business College campus Elementary/middle/high school campus Airport Highway or Freeway other

Which law enforcement agency was involved:
choose one U.S. Marshals City or County Police Agency Highway Patrol Airport Police Agency Transit Police Agency State Trooper Sheriff Department Campus Police Agency Probation Department Mall Security Other Peace Officer

Motivation of incident :
Race-Racism Sexism-Gender Disability Sexual Orientation-Homophobia Religion/Faith Conviction History/Status

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