Crime Prevention / BULLYING
VICTIMS INCIDENT REPORT / Date:_____/_____/______
Location of Intake ______
Intake Type:
___ Victim ___ Concerned Citizen / Call Back Needed ___Yes ___No
Primary Language______
Case Type(s)
(Check one) / ___B:School Bullies ___C: Cyber Bullies ___S: Neighborhood Bullies
Callers Name:______
Callers Address:______
______
Preferred Phone Contact# ______
Preferred Email contact______/ Caller presents as (check one):
___ Family ___Friend ___Lover/Partner ___Offender
___ Organizational Survivor/Victim ___Service provider
___ Survivor/Victim ___ Witness
___ Other(specify)______
VICTIM INFORMATION
Victim is: ___ Person ___ Organization
Name:______
Address:______
______
Phone:______
Email:______/ AGE:
___ < 14
___ 15-18
___ 19-24
___ 25-29
___ 30-39 / ___ 40-49
___ 50-59
___ 60-69
___ 70-79
___ > 80 / GENDER ID (Check all that apply)
___ Male
___Female
___ Non-Transgender
___ Transgender
___ Self-Identified/Other(specify)
___ Not disclosed
Age: (optional)______
DOB____/____/_____
Prefers contact via: / ___ Phone / ___ Email / IMMIGRATION STATUS
___ U.S. Citizen
___ Permanent Resident
___ Undocumented
___ Other
___ Not disclosed
Ok to say SpeakOut? / ___ Yes / ___ No
Ok to leave message? / ___ Yes / ___ No
Ok to email? / ___ Yes / ___ No
RACE/ETHINICITY (Check all that apply):
___ Arab/Middle Eastern
___ Asian/Pacific Islander
___ Black/African American/African Descent
___ Indigenous/First People/Native American/American Indian
___ Latino/a
___ Caucasian/White
___ Self-Identified/Other (specify)
______
___ South Asian
___ Not disclosed / SEXUAL ORIENTATION:
___ Bisexual
___ Gay
___ Heterosexual
___ Lesbian
___ Queer
___ Questioning /Unsure
___ Same Gender Loving
___ Self-Identified/Other ______/ HIV STATUS
Victim is HIV+?
___ Yes ___ No ___Not Disclosed
If yes, check all that apply and specify:
___ Blind/Visually impaired
___ Deaf/Hard of hearing
___ Learning disability
___ Mental Health
___ Physical
INCIDENT INFORMATION
Is this a “Repeated Incident”? ___ Yes ___ No / If Yes: Number of Previous Incidents ___1 ___2-5 ___6-10 ___11+ Ongoing since:___/___/___
Date of Incident ___/___/___ Time of Incident __:__am/pm
Where incident occurred:______
Location/Address Incident ______Zip______
Have you reported incident(s) to? “Check all that apply”
Parents ___ Yes ___No If yes, did they help? ___ Yes ___No
Teachers ___ Yes ___No If yes, did they help? ___ Yes ___No
Principal ___ Yes ___No If yes, did they help? ___ Yes ___No
School Superintendent ___ Yes ___No
If yes, did they help? ___ Yes ___No
Previous Police report filed? ___ Yes ___No
If yes, did they help? ___ Yes ___No / Date of Incident ___/___/___ Time of Incident __:__am/pm
Where incident occurred:______
Location/Address Incident ______Zip______
Have you reported incident(s) to? “Check all that apply”
Parents ___ Yes ___No If yes, did they help? ___ Yes ___No
Teachers ___ Yes ___No If yes, did they help? ___ Yes ___No
Principal ___ Yes ___No If yes, did they help? ___ Yes ___No
School Superintendent ___ Yes ___No
If yes, did they help? ___ Yes ___No
Previous Police report filed? ___ Yes ___No
If yes, did they help? ___ Yes ___No
Date of Incident ___/___/___ Time of Incident __:__am/pm
Where incident occurred:______
Location/Address Incident ______Zip______
Have you reported incident(s) to? “Check all that apply”
Parents ___ Yes ___No If yes, did they help? ___ Yes ___No
Teachers ___ Yes ___No If yes, did they help? ___ Yes ___No
Principal ___ Yes ___No If yes, did they help? ___ Yes ___No
School Superintendent ___ Yes ___No
If yes, did they help? ___ Yes ___No
Previous Police report filed? ___ Yes ___No
If yes, did they help? ___ Yes ___No / Date of Incident ___/___/___ Time of Incident __:__am/pm
Where incident occurred:______
Location/Address Incident ______Zip______
Have you reported incident(s) to? “Check all that apply”
Parents ___ Yes ___No If yes, did they help? ___ Yes ___No
Teachers ___ Yes ___No If yes, did they help? ___ Yes ___No
Principal ___ Yes ___No If yes, did they help? ___ Yes ___No
School Superintendent ___ Yes ___No
If yes, did they help? ___ Yes ___No
Previous Police report filed? ___ Yes ___No
If yes, did they help? ___ Yes ___No
TELL US WHAT HAPPENED?
In your description of the incident(s), please make sure that you give the scenario of the violence, including the use of weapons, the specific anti-LBGT/SGL words used (if any), and extent of injuries.
Type(s) Of Violence
(Check All That Apply) / Violence Against Person
(Check All That Apply) / Location Type(check one):
___ Physical Violence Against Person (check all that apply):
___ Forced use of alcohol/drugs
___ Murder
___ Attempted Murder
___ Physical violence
___ Attempted physical violence
___ Robbery
___ Attempted robbery
___ Sexual Violence
___ Attempted sexual violence
___ Self-Injury
___ Suicide
___ Attempted Suicide
___ Other self harming behavior (cutting, etc.)
Was a weapon involved?
___ Yes ___ No ___ Unknown
List weapon:______
Did the person die?
___ Yes ___No ___ Unknown
If yes, severity of injury:
___ No injuries requiring medical attention
___ Injuries requiring medical attention (specify):
___ Needed but not received
___ Outpatient (Clinic/MD/ER)
___ Hospitalization/Inpatient
___ Not disclosed
Type of injury (specify)
______
______/ ___Other Violence Against Person (check all that apply):
___ Blackmail
___ Bullying
___ Discrimination
___ Eviction(related to landlord)
___ False police reporting
___ Financial
___ Harassment (Not in person: mail, email, tel, etc.)
___ Isolation
___ Medical
___ Psychological/Emotional abuse
___ Sexual Harassment
___ Stalking
___ Threats/Intimidation
___ Use of immigration status
___ Verbal harassment in person
___ Violence against pet
___ Pet injured
___ Per killed
___Other(specify)______
___ Police violence/misconduct
(check all that apply)
___ Excessive force
___ Police entrapment
___ Police harassment
___ Police raid
___ Unjustified arrest
___ Reported to internal/external police monitor
___ Yes ___ No ___ Will Report
___ Attempted, complaint not taken
___ Not available ___ Unknown
___ Other (specify):______
______/ ___Hanging Out area
___ In or near LGBTQ-identified venue
___ Media
___ Non-LGBTQ-identified venue (playground, restaurant, public transportations, etc.)
___School Bus
___ Public Transportation
___ Private Residence
___ School/College/University
___ Shelter
___ Street/public area
___ Other(specify):______
___ Workplace (place where survivor or abusive person is employed)
___ Not disclosed
Website/app:
___Facebook ___Twitter ___ Craigslist
___School Blog
Other website/apps(specify):
______
MOTIVE (Check all that apply):
___ Anti-Homelessness
___ Anti-Immigrant
___ Anti-LGBQ/Homophobia/Biphobia
___ Anti-Sex Worker
___ Anti-Transgender/Transphobia
___ Disability
___ HIV/AIDS-related
___ Racist/Anti-ethinic
___ Religious (specify perceived religion)
______
___ Sexist
___ Other(specify)______
___ Unknown
HAVE YOU EXPERIENCED ANY OF THIS?
___ Use alcohol and drugs
___Skip school
___Experience in-person bullying
___Be unwilling to attend school
___Receive poor grades
___Have lower self-esteem
___Have more health problems
___VIOLENCE AGAINST PROPERTY(check all that apply)
___ Arson
___ Theft
___ Vandalism
___ Other (specify):______
*Estimated stolen/damaged property value:
$______
OFFENDER INFORMATION
Total Number of Offenders: ______/ Is offender a member of identifiable hate group? ___ Yes ___ No ___Unknown / Hate Groups Name
______
Vehicle used in case/incident? ___ Yes ___ No If yes, describe vehicle:______License______
Note: If there is more than one offender, CREATE A DESIGNATION FOR EACH OFFENDER for use in the blank following each demographic category below (A,B,C, ect.)
Offender A Name:______Offender B Name:______Offender C Name:______
OFFENDER(S) KNOWN TO SURVIVOR? ___Yes ___ No If yes, fill out 1), below. If no fill out 2).
1) KNOWN OFFENDER(S): RELATIONSHIP TO VICTIM:
___ Acquaintance/Friend ___Studentattend another school ___Classmate ___Relative of Landlord/Tenant/Neighbor
___ Relative/Family ___ Other (specify):______Unknown
2) UNKNOWN OFFENDER: RELATIONSHIP TO VICTIM:
___ Stranger ___ Other (specify):______Unknown
AGE
___14 OR under ____
___ 15-18 ___
___ 19-24 ___
___ 25-29 ___
___ 30-39 ___
___ 40-49 ___
___ 50-59 ___
___ 60-69 ___
___ 70-79 ___
___ 80 or over ___
___ Not disclosed___
Age (if unknown)____
D.O.B.: ___/___/____ / GENDER ID (check all that apply)
___ Man____
___ Woman____
___ Non-Transgender ____
___ Transgender ____
___ Self-Identifier/Other__
(specify):______
___ Not Disclosed
___ Unknown
INTERSEX
___ Yes ___ No
___ Not disclosed ___ Unknown / RACE/ETHINICITY
(check all that apply)
___ Arab/Middle Eastern
___ Asian/Pacific Islander
___ Black/African American/African Descent____
___ Indigenous/First People/Native American/American Indian
___ Latina/o
___ White/Caucasian
___Self-Identified/Other______
______
___ South Asian
___ Not disclosed
___ Unknown / SEXUAL ORIENTATION
___Bisexual ___ Gay ___Heterosexual ___Lesbian ___Queer ___SGL
___Questioning/Unsure
___Self-identified/Other (specify):______
______
___ Not Disclosed ___ Unknown
OFFENDER USE OF ALCOHOL/DRUGS
Alcohol involved?
___ Yes ___ No ___Not disclosed ___ Unknown
Drugs Involved?
___ Yes ___ No ___Not disclosed ___ Unknown
If yes, describe:
______
SERVICES PROVIDED
REFERRALS
(check all that apply)
___ Counseling
___ Housing
___ Legal
___ Shelter
___ DV
___ Homeless
___ Medical
___ Police
___ Other(specify):
______/ ADVOCACY (check all that apply)
___Housing ___ Legal ___ Medical
___ Mental Health ___ Police / FOLLOW-UP NEEDED?
___Agency follow-up
___Caller follow-up
ACCOMPAINIMENT
___ Court
___Hospital
___Police
___Other (specify):
______/ OTHER SERVICES (check all that apply):
___ Safety Planning
___ Court Monitoring
Next Court Date:
______
is a member of The National Coalition of LBGTQ Anti-Violence Programs