Cia Siab, Inc. Hate Incident Report Form
The purpose of this reporting form is to give individuals in the Hmoob community an outlet to report hate incidents in a confidential manner. We also encourage anyone who is non-Hmoob to report any hate incidents that has occurred to them as well. Examples may include, but are not limited to, the use of degrading language or slurs (spoken or written) and physical harm suffered based on identity or perceived identity.

A hate incident is any physically or verbally harmful act that is motivated by, or appears to be motivated by, any of the following: race/ethnicity, religion, national origin, immigration/citizenship status, sexual orientation, gender identity or expression, economic status, language, age, pregnancy or family/marital status, disability, veteran or military status, or any other identity status.

What happens after I submit this report?
Every effort will be made to evaluate your report promptly. However, the timing and manner in which Cia Siab, Inc. addresses the report will vary depending on the information provided and whether you wish to remain anonymous. Cia Siab, Inc. cannot guarantee it will respond to all reports. Our ability to provide assistance and to use your report to fuel training and/or policy development will be enhanced if you provide more factual detail.

If you would like to report over the phone or need language assistance and support, please contact:
Mai Lee, Social Justice Director
(608) 615-7117 ext. 5
What was your role in this incident?
Please be as detailed as possible about this incident you are reporting.
Date of the incident: *
MM
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DD
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Location of incident: City *
Location of incident: State *
Location of Incident (i.e. grocery store, school, home, etc.) *
This hate/bias incident targets (please check all that apply): *
Required
Did the incident involve any of the following (check all that apply)?
Describe the incident (please be as specific as you are able):
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