Complete the following form to report discrimination, a hate crime, harassment, or contact the Human Relations Committee on another matter.

A separate form must be completed for each incident.

Date of incident: *

Type of incident:*

Discrimination Harassment

Hate Crime Other

Time of incident:*

Name the person(s) responsible for committing the incident (if known):

List the name(s) of any witness(es) (if applicable):

Describe the incident:

Have there been prior occurrences? *

If yes, where and when?

Name: *

Address:*

Contact Number: *

Email Address: