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Traffic Stop Form
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Can the Fair, Fines, and Fees Coalition contact you about your experience?
Yes
No
Clear selection
If you answered "Yes" above, please provide your name and the best way for us to reach you
Your answer
Where were you located when you were pulled over?
Your answer
What was the date you were pulled over?
MM
/
DD
/
YYYY
What was the approximate time you were pulled over?
Your answer
To the best of your knowledge, what was the reason you were pulled over?
Your answer
Please describe your interaction with the police:
Your answer
What is your age?
Your answer
What is your gender?
Male
Female
Other
Prefer not to say
Clear selection
What is your race?
Select all that apply
Asian
African American/Black
Caucasian/White
Latinx
Native American
Pacific Islander
Prefer not to say
Other:
Are you a member of the following communities?
Select all that apply
Refugee
Immigrant
Person of Color
None of the above apply to me
Which best describes your sexuality
Heterosexual
Homosexual
Bi/Pansexual
Asexual
Other
Prefer not to say
Clear selection
Which describes you?
Select all that apply
Transgender
Cisgender
Non-binary
Queer
Gay/Homosexual
Straight/Heterosexual
Bi/Pansexual
Asexual
Other:
Is there any additional information about your experience you want to record?
Your answer
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