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Appendix 2

Incident Form for Documentation of Civil Rights Abuses (English)

INCIDENT REPORT FORM

FOR VIOLENCE OR HARRASSMENT OF PERSON EXPERIENCING HOMELESSNESS

The purpose of this incident report form is to assist advocates and people experiencing homelessness in tracking cases of abuse and/or mistreatment. The victim’s signature at the end of the form indicates his/her consent to use the information in reports and/or presentations to various groups, including the media. The victim should not sign the form if s/he does not consent. (See signature instructions at the end.)

Information of Victim (optional)

Name

Address or Way to contact

Phone number or way to contact

Email

Victim’s identity/characteristics (optional) This information will help to determine factors that have played a role in the incident. Fill out any applicable category.

Race

Religion

Ethnicity/National Origin

Sexual Orientation

Gender

Disability

Incident Location

Date and Time

Location: Be as specific as possible, for example, on the corner of 14th and K between the metro entrance and the coffee stand.

Losses/Grievances, e.g. destruction or confiscation of property, arrest, arson, assault/battery, murder

Description of Incident: Include as many factual details as possible, e.g. any police response and involvement and any witness information. Use back or attach sheets if necessary.

IF POLICE WERE INVOLVED: Name of officer

Badge number

Witness:

Name

Address or Way to contact

Phone number or way to contact

Email

 

Your signature immediately below indicates your consent for us to use the information on this form in reports and/or presentations to various groups, including the media. This refers to information only; actual names/identification of individual victims will be withheld as a matter of course unless otherwise agreed to in advance. You DO NOT have to sign here if you do not consent.

Signature

Date

Resolution/Outcome (if any)

Reported by

Date

Please print and send to:
National Coalition for the Homeless
2201 P St NW
Washington, DC 20037
Phone: 202.462.4822 | Fax: 202.462.4823
Email: info@nationalhomeless.org

 

Full report in .pdf form | Introduction | Background | Methodology | Problem Statement/Consequences of Criminalization | Model Programs | Conclusions & Recommendations | The Cities Included in this Report | Meanest Cities | Narratives of the Meanest Cities | Narratives of the Other Cities | Prohibited Conduct Chart | Survey Questions | Incident Report Form: English & Incident Report Form: Spanish | Sources