Hate Incident Report

HCCA Hate Incident Report
The purpose of this reporting form is to give individuals in the Hmoob community an outlet to report hate incidents in a confidential manner. Examples may include but are not limited to the use of degrading language or slurs, spoken or written and physical harm done based on race, gender, sexual orientation, religion, disability, etc .

This form does not substitute for reporting. If you are comfortable, we highly encourage you to report this to the police. For language assistance and support please contact the Hmoob Cultural and Community Agency at 608-781-5744.

About you
Gender
Race/Ethnicity
Please note that we highly encourage you to identify as it would help us accurately with our data and reporting. If you wish not to be identified, please tell us why.
Your answer
Age:
Your answer
Date of the incident
MM
/
DD
/
YYYY
Location:
Your answer
Describe the incident:
Your answer
How did this incident impact you:
Your answer
If you would like to be contacted to discuss this further and get support please provide your contact information below.
Your answer
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