Report an Incident

Please fill out this form clearly, describe the incident with enough information so we can better understand your complaint. The information you provide will remain confidential during the investigation and verification of the incident.

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Incident Report/Discrimination Claim

Name*

Email

Phone Number

Address

City

State

Zipcode

Incident Information

Category of Discrimination*

Cause/Reason of Discrimination

Incident reported to:

Date of incident (approx. date)*

Time of incident (approx. time)

Address or location of incident*

Involved party name(s)

Will you be willing to talk to the media?*

Please use the following space to describe the incident(s)

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