Incident Report Form
This form is to be utilized to report an incident of violence or discrimination that has taken place against a member of the sexual and gender minority community. All information collected is used for the sole purpose of tracking incidences of violence and discrimination that occur against community members. Information may be turned over to law enforcement officials in accordance with any applicable federal, state, or local laws.
First and Last Name
Date of incident
Zip Code where incident took place
Incident Involving (select all that apply)
Health Care Provider
Please provide a description of the incident
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This form was created inside of The PRIDE Center of Maryland.
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