Pennsylvania Inter-Agency Task Force on Civil Tension Bias-Related Incident Reporting Form The PA Inter-Agency Task Force on Civil Tension welcomes and encourages reports of all Bias-Related Incidents in Pennsylvania. Read This First! Reports of Bias-Related Incidents using this form are currently being received for informational purposes only. Submitting this report DOES NOT constitute a formal report to governmental or law enforcement authorities. NO IMMEDIATE, ACTIVE RESPONSE IS ASSURED. If you are aware of a potentially criminal act, dial 911 to contact the police with jurisdiction in the local area where the possible crime occurred. If you are aware of potentially unlawful discrimination, some other violation of civil law, or a serious, but lawful situation that you feel needs prompt attention in order to prevent escalating tensions, please contact one of these agencies: Education and Community Services PA Human Relations Commission PO Box3145 Harrisburg, PA 17105-3145 (717) 783-8264 FAX: (717) 772-4340 Heritage Affairs Office Bureau of Criminal Investigations Pennsylvania State Police 1800 Elmerton Avenue Harrisburg, PA 17110-9718 (717) 772-5112 FAX: (717) 705-2306 Civil Rights Compliance Section Office of the Attorney General 14th Floor - Strawberry Square Harrisburg, PA 17120 (717) 787-0822 FAX: (717) 787-1190 ------------------------------------------------------------------+ CONTACT INFO | ------------------------------------------------------------------+ | First Name: ________________________________________ | | Last Name: ________________________________________ | | Address: ________________________________________ | | Address: ________________________________________ | | City: ____________________ | | State: ____________________ Zip: __________ | | Telephone 1: (______) ______-________ | | Days/Times at this number _______________________________ | | Telephone 2: (______) ______-________ | | Days/Times at this number _______________________________ | | Email Address:________________________________________ | | ------------------------------------------------------------------+ ------------------------------------------------------------------+ INCIDENT INFO | ------------------------------------------------------------------+ | Filing Date: ____/____/________ (Today's date) | | Incident Date: ____/____/________ | | Incident Time: ____:________ am/pm | | Location Incident Occurred: _____________________________________ | | County: ___________________________________________________ | | Municipality: ___________________________________________________ | (City, town, borough, village, and/or township) | | Type of Location: (Elementary school, private residence, place of | worship, retail store, university, public street, government | building, etc.) | | _________________________________________________________________ | | _________________________________________________________________ | | _________________________________________________________________ | | | How Did You Learn About the Incident? (Newspaper, TV, witness, | directly involved, etc.) | | _________________________________________________________________ | | _________________________________________________________________ | | _________________________________________________________________ | | _________________________________________________________________ | | _________________________________________________________________ | | _________________________________________________________________ | | _________________________________________________________________ | | _________________________________________________________________ | | _________________________________________________________________ | | _________________________________________________________________ | | Parties Involved: (Names and/or descriptions of people involved; | include descriptions that relate to why you feel this incident | was bias-related, race, color, ethnicity, age, religion, etc.) | | _________________________________________________________________ | | _________________________________________________________________ | | _________________________________________________________________ | | _________________________________________________________________ | | _________________________________________________________________ | | _________________________________________________________________ | | _________________________________________________________________ | | _________________________________________________________________ | | _________________________________________________________________ | | _________________________________________________________________ | Description of Incident: (Provide a brief description of what | occurred. There is no need to repeat the above information.) | | _________________________________________________________________ | | _________________________________________________________________ | | _________________________________________________________________ | | _________________________________________________________________ | | _________________________________________________________________ | | _________________________________________________________________ | | _________________________________________________________________ | | _________________________________________________________________ | | _________________________________________________________________ | | _________________________________________________________________ | | Why do you think this was a bias-related incident? (Give a brief | explanation. What kind of bias was involved?) | | _________________________________________________________________ | | _________________________________________________________________ | | _________________________________________________________________ | | _________________________________________________________________ | | _________________________________________________________________ | | _________________________________________________________________ | | _________________________________________________________________ | | _________________________________________________________________ | | _________________________________________________________________ | | _________________________________________________________________ | ------------------------------------------------------------------+ Mail or Fax To: PA Inter-Agency Task Force on Civil Tension c/o PA Human Relations Commission PO Box 3145 Harrisburg, PA 17105-3145 FAX (717)772-4340 Remember . . . Reports of Bias-Related Incidents using this form are currently being received for informational purposes only. Submitting this report DOES NOT constitute a formal report to governmental or law enforcement authorities. NO IMMEDIATE, ACTIVE RESPONSE IS ASSURED. If you are aware of a potentially criminal act, dial 911 to contact the police with jurisdiction in the local area where the possible crime occurred. If you are aware of potentially unlawful discrimination, some other violation of civil law, or a serious, but lawful situation that you feel needs prompt attention in order to prevent escalating tensions, please contact one of the three agencies listed on the first page of this form.