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2. This form is intended to obtain information about and/or to report incidents occurring in our community. Third party or anonymous complaints will be accepted, but please be aware that anonymous complaints can sometimes be difficult to investigate as an investigator may need additional information and the complainant may be the only source available. For this reason, please consider providing contact information when submitting your complaint.
4. 
   
6. Would you like to remain anonymous?

   1. Yes
   2. No
8. You are......

   1. Victim
   2. Witness
   3. Friend
   4. Other
10. If other, please elaborate:
12. First Name:
14. Last Name:
16. Street Address:
    (for example,
    435 Ryman St)
18. City:
20. State:
22. E-Mail:
24. Phone #:
26. 
    
28. Date of Incident:
30. Time:
32. Location:
34. 
    
36. Please describe the incident:
38. 
    
40. Victim First Name:
42. Victim Last Name:
44. Victim Contact Information:
46. 
    
48. Does the victim want contact from an official?

    1. Yes
    2. No
50. Do you want contact from an official?

    1. Yes
    2. No
52. 
    
54. The incident was or appeared to be:
    (select all that apply)

    1. Verbal Assault or Slur
    2. Threat of Outing
    3. Graffiti
    4. Pursuit/Chase
    5. Threat of Physical Assault
    6. Leafleting
    7. Physical Assault
    8. Stalking
    9. Sexual Harassment
    10. Public Indecency
    11. Phone Harassment
    12. Unwanted Letter/Email
    13. Other
56. If you selected other, please explain:
58. 
    
60. You believe the incident was because of:
    (Select all that apply. If none apply, this is not a hate crime)

    1. Gender
    2. Creed
    3. Religion
    4. Ethnicity
    5. Disability
    6. Race
    7. Sexual Orientation
    8. National Origin
    9. Nationality
    10. Age
    11. Appearance/Color
62. If you selected other, please explain:
64. 
    
66. To your knowledge, was this incident reported to any police agency?

    1. Yes
    2. No
68. If so, which agency?

    1. Missoula Police
    2. Missoula County Sheriff
    3. UM Police
70. 
    
72. Thank you for taking the time to step up and help us combat hate crimes and bias incidents in Missoula.
Leave This Blank:


74. 1. Receive an email copy of this form.
75. Email address

    This field is not part of the form submission.

76. Submit

* indicates a required field