Civil Rights Incident Report Form
Please provide detailed information about the civil rights incident you are reporting. Your responses will help ensure a thorough review of the matter.
Full Name of Reporter
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Incident
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Location of Incident
*
Type of Incident
*
Discrimination (race, gender, religion, etc.)
Harassment
Denial of Access or Service
Retaliation
Other
Please describe the incident in detail
*
Names of individuals or organizations involved (if known)
Were any authorities or law enforcement notified?
*
Yes, law enforcement
Yes, other authorities
No
Please upload any supporting documentation or evidence
Upload a File
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Choose a file
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Would you like to be contacted regarding this report?
*
Yes
No
Submit Report
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