ORGANIZATION NAME *COUNTY *Date of Report *Type of incident *Select the type of incidentBlackmail/ExtortionSexual harassmentVerbal abusePhysical violationWrongful arrestOtherDate when incident happened *Time when incident happenedHoursMinutesAMPMStreet Address *Apartment, building etcCityVictim's NameVictim's SOGIELesbianBisexualTransgenderIntersexQueerAny information on perpetratorDescription of incident *Provide police station and OB number if the case was reportedIf solved in another way please describe *Ongoing support/follow up *Additional notes/Challenges if anySubmit your report
