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Email address
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Physical assault or attack to person
Damage to property
Verbal abuse, harrassment, or threats of harm to person and/or property
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Yes
No
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PERSONAL INFORMATION
First and Last Name
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Phone Number
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INCIDENT
Date of Incident
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Time of Incident
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Location of Incident
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Nature of Incident
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Detailed Description of Incident
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Was the incident reported to law enforcement?
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If yes, what law enforcement agency?
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Was the incident reported to the media and/or community organization(s)?
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If yes, what media outlet(s) and/or community organization(s)?
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