• Civil Rights Violation Report

    Use this form to document a suspected civil rights violation, describe what happened, identify the people involved, and request follow-up.

  • Reporter Information

  • Is this report being submitted anonymously?*
  • Preferred contact method
  • Format: (000) 000-0000.

  • Affected Person Information

  • Is the affected person the reporter or someone else?*
  • Does the affected person need communication accommodations?*

  • Incident Details

  • Incident date*
     - -

  • Type of Alleged Violation

  • Type(s) of Alleged Violation*
  • Primary Type of Alleged Violation*

  • People Involved and Witnesses

  • Evidence and Documentation

  • Do you have supporting evidence?*
  • Have you preserved the original files or items?

  • Impact and Immediate Needs

  • How has the incident affected the person?*
  • Is there an immediate safety concern?*

  • Desired Follow-Up

  • Requested Follow-Up Actions*
  • Preferred Follow-Up Contact Method*
  • Should be Empty:
Select theme:
  • Default
  • Blue
  • Red
  • Brown
  • Green
  • Black
  • Pink
  • Dark Blue
  • Purple