1. Date of Report:

Fill in the date the report is first written

2. Reporting Party:

Enter the name and address, and phone number where the person making the report can be contacted

3. Date of Incident:

Fill in the date of the incident

1. If the incident continued over a period of 30 days or less put in the date the first incident occurred and include the approximate date and times of other incidents in the Narrative
2. If the incident is one of a number of incidents over an extended period, enter the date the last incident occurred and in the Narrative state, "This is the last of a number of incidents beginning [enter approximate date the first incident occurred]"

4. Time of Incident:

Approximate time incident occurred on date listed for the incident

5. Location:

List address or other description to identify where the incident occurred on the date and time indicated, i.e. 150 Main Street, Plaza Park, or sidewalk on the west side of 3rd Street between Pine and Elm

6. Report Taker:

Enter your name and a phone number that can be used to contact you about this report

7. Agency:

Enter your organization or agency name

8. Type of bias:

Check off each bias considered to be part of the motivation for the incident and use the space after "Anti"- to designate the specific group targeted.  For example, if the incident is directed against Koreans, check National Origin and write "Korean" after the prefix "Anti-"

a. If the incident is only partially based on bias, check the bias involved and include the evidence for bias in the Narrative section.  For example, if someone uses a racial slur during a robbery, check "race" and use the Narrative section to describe the robbery and actions of the perpetrator that showed bias was also part of the motivation.

b. If there is no evidence of bias except for the "gut feeling" of the victims, do not dispute that the incident was inspired by bias, but explain to the reporting party that you need some actual evidence before you can take the report.  refer to the guidelines, if needed, to refresh your memory of the types of evidence needed to show bias

• Racial : Anti-?
• National Origin: Anti-?
• Relgion: Anti-?
• Immigrant: Anti-?
• Elderly

• Disability Type
• Gender: Anti-?
• Sexual Orientation: Anti-?
• Other

9. Type of incident

Check each action that applies.  If the action is not on the list, check "Other" and describe the action.  You can include more information in the Narrative

• Slurs
• Verbal threat
• Threat with apparent
  intent to carry it out
• Physical assualt-no weapons

• Physical assualt - weapons
• Physical injury
• Homocide
• Other

• Graffiti on public property
• Graffiti on private property
• Cross burning
• Arson

• Property damage-public
• Property damage-private
• Explosion
• Other

10. Other Parties:

List each relevant party and enter the code to describe their relation to the incident.  Use Code Letter "O" to list people not described by the codes but who are named in the Narrative
Codes: V=victim, D=victim's domestic partner, W=witness, F=family, O=other

11. Suspects:

Use this space to include any information known about the perpetrators.  If no information is known, leave this space blank.  Provide relevant information about suspects even if their identities are not known, e.g. "Male," "White," "Approx. 16 years old," or "part of group of other males, all with shaved heads."  If known, provide information on affiliation that would help determine if this is a part of a group activity, e.g. name of hate group, school, gang, etc.

12. Responding Agency:

List any public or private agencies contracted prior to your receipt of the report.  If known, enter the name and number for person to contact at the agency, e.g. "Sandi Bargioni, (415)553-1139."

13. Narrative

Describe the incident from the viewpoint of the person giving the report.  Be sympathetic and assume that the person making the report is telling the truth.  If contradictory statements are made, ask the reporting party to clarify them.

One way to make sure the narrative is complete is to pretend that you are watching the incident as it is happening.  If you can't picture everything in your mind, ask the reporting party for more details.  for example, if a woman is reporting a swastika painted on her house, you might ask questions to determine: approximately what time she thinks it happened; where was the swastika painted; how the perpetrators got to the house; whether other people might have seen it happen; how the swastika was applied (i.e. spray can, brush) and its color and size; whether anything else was painted or whether there is any other evidence; whether she has any ideas as to why her house was vandalized and who did it

If necessary, call the reporting party back to get additional information so that you can provide a complete and accurate narrative.

14. Action taken:

Describe only what you did or what you told the victim or reporting party to do.  Any relevant action taken by other parties following the incident should be included in the Narrative

15. Recommendations:

State actions you feel should be taken.  include follow-up referrals you made to make sure the victim receives needed services

16. Comments

Use this space to state your concerns about the incident, about the reporting party, or other issues that should be known by the person reading the report

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