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Anti-Violence Program-MKE LGBT Community Center
REPORTING FORM
Every day, across the state of Wisconsin, LGBTQ people face bias and discrimination. Unfortunately, they also are often victims of violent crime. These incidents of violence often go unreported. By reporting the incident(s), you are helping AVP staff to track hate crimes, intimate partner violence, sexual violence, bias-related incidents, and other forms of violence occurring within our community. This information will only be used to collect data in order to find out what is going on in the community.
Please complete this form if you have ever been a victim, or have personal knowledge of other LGBTQ hate-related harassment, property damage, or violence.
You may choose to remain anonymous and do not have to provide us with information that would reveal your identity. All information you provide is STRICTLY CONFIDENTIAL and will not be shared with anyone else including law enforcement.
This form is voluntary. If you have further questions, an advocate is available to speak with you at: 414.292.3072.
How did you hear about us?
*
How do you identify your sexual orientation?
*
Lesbian
Gay
Bisexual
Heterosexual
Queer
Questioning
Other (please describe below):
Prefer not to disclose
How do you identify your gender? Please check all that may apply:
*
Woman
Man
Transgender
Non-transgender
Trans Man
Trans Woman
Genderqueer
Gender non-conforming
Self-identified/other (please describe below):
Prefer not to disclose
Intersex:
Yes
No
Not disclosed
How do you describe your race? Please check all that may apply:
*
Arab/Middle Eastern
Asian/Pacific Islander
Black/African American/African decent
Latina/o
Native American
White/Caucasian
Self-identified/other (please describe below):
Prefer not to disclose
What is your date of birth?
You may give the year of your birth, if you prefer not to disclose date of birth.
*
What is your zip code?
*
What type of violence occurred? Please check all that may apply:
*
Hate violence
Sexual Violence
Intimate Partner Violence/Domestic Violence
Physical assault/battery
Harrasment
Stalking
Police misconduct
Police violence
Other
What time did the incident occur? (ex. 9:30am, evening, after sunset, etc)
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When did this incident occur?
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MM
/
DD
/
YYYY
Where did this incident happen? Please be as descriptive as possible, include address or cross streets, name or type of facility (bar, private residence, public space, work, etc):
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What happened? Please give as much information as is comfortable for you.
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How many victims were there, including you?
*
Was anyone injured?
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Please select
Yes
No
Unknown
Were the police called?
*
Please select
Yes
No
How many offenders were there?
*
Please describe the offender(s), including age, race/ethnicity, gender identity, sexual orientation, and any other known information, whether the person was in law enforcement, works at a business. (Please identify multiple offenders as "Offender 1," "Offender 2"
*
Did anyone know the offender?
*
Would you like to be contacted by AVP?
*
Please select
Yes
No
If you chose "Yes," indicate how you would like to be contacted:
Please select
Phone only
Email only
Phone or email is fine
Email
Phone
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###
-
####
Name (you may provide a fake name):
*
Please check off all that apply:
Yes, it is okay to leave a message on my phone
Yes, it is okay to mention AVP over the phone
Yes, it is okay to mention AVP over email.
No - it is NOT okay to leave a message on my phone
No - it is NOT okay to mention AVP over the phone
No - it is NOT okay to mention AVP over email.
Is there anything else that you would like to tell us?
Thank you for telling AVP about what happened to you. We are here if you need us. If you need support, AVP can help you – we can talk with you, help advocate for you and help you get what you need. If you would like to speak to someone about what has happened to you, please call 414.292.3072 to speak with our bilingual advocate (English/Spanish) All calls are confidential.
2013 - Milwaukee LGBT Community Center - Anti-Violence Program
1110 North Market Street, Second floor, Milwaukee, WI 53202
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