1. Are you a Victim or a Witness? --choose one-- Witness Victim

Victim Information

2. Gender: --choose one-- Female Male

3. Race/Ethnicity: --choose one-- American Indian or Alaskan Native Asian Black or African American Hispanic or Latino Native Hawaiian or Other Pacific Islander White or Caucasian

4. Age:

Hate Incident Information

7. Date of incident: mm/dd/yyyy

8. Time of incident:

9. Location of incident:

10. Number of perpetrators:

11. Describe the incident. Please be as specific as possible:

12. Would you like to be contacted by The Equity, Affirmative Action and Compliance Office? --none-- Yes No

If you are under 18 years of age and do not want to make an official police report, please omit your name and contact information.

(Optional) If you are willing to be contacted, please provide the information below.

13. Name:

14. Phone:

15. Email:

16. How would you prefer to be contacted? --none-- phone email either

Perpetrator Information
(if known; otherwise, scroll to the end of the form and click "submit")

17. Gender: --choose one-- Female Male

18. Race/Ethnicity: --choose one-- American Indian or Alaskan Native Asian Black or African American Hispanic or Latino Native Hawaiian or Other Pacific Islander White or Caucasian

19. Age:

22. Please describe the nature of your relationsip with the perpetrator prior to the incident (friend, acquaintance, stranger, etc.):

23. Please include other information, including information regarding additional perpetrators: