| Victim's Information |
| Name: |
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| Gender: |
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| Address 1: |
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| Address 2: |
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| City: |
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| State: |
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| Zip: |
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| Country: |
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| Daytime Phone: |
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| Evening Phone: |
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| Email: |
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| Incident Information |
| Other Victims (Names):
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| Category of Discrimination: |
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| Context of Discrimination: |
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| Cause/Reason of Discrimination: |
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| Date of Incident:
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| Time of Incident:
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| Address/Location of Incident:
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| Involved Party Name(s):
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Incident Description:
(Please include all relevant information, including names and titles of other
parties involved. Example: For air travel related incidents include airport,
traveling from/to, airline name, flight details, etc.)
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| Would you be willing to talk to media?: |
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| We will publish this incident in a report. Doyou want your
identity to remain confidential : |
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| Reporter's Information |
| I am the victim, use the information provided in the "Victim’s
Information" section: |
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| Name: |
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| Gender: |
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| Address 1: |
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| Address 2: |
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| City: |
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| State: |
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| Zip: |
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| Country: |
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| Daytime Phone: |
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| Evening Phone: |
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| Email: |
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